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A  CLINICAL  MANUAL  OF 

MENTAL  DISEASES 


BY 

FRANCIS  X.  DERCUM  A.  M.,  M.  D.,  Ph.  D. 

Professor  of  Nervous  and  Mental  Diseases,  Jefferson  Medical  College, 
Philadelphia;  Consulting  Neurologist  to  the  Philadelphia  General  Hospital; 
Ex-President  of  the  American  Neurological  Association,  of  the  Philadelphia 
Neurological  Society,  and  of  the  Philadelphia  Psychiatric  Society;  Foreign 
Corresponding  Member  of  the  Neurological  Society  of  Paris,  and  of  the 
Psychiatric  and  Neurological  Society  of  Vienna;  Member  of  the  Royal 
Medical  Society  of  Budapest,  etc.,  etc. 


SECOND  EDITION,  REVISED 


PHILADELPHIA  AND  LONDON 

W.    B.    SAUNDERS   COMPANY 

1917 


Copyright,  igi3,  by  W.  B.  Saunders  Company. 
Reprinted  February,  igi4.     Revised,  re- 
printed, and  recopyrightcd 
November,  1917 


Copyright,  1917,  by  VV.  B.  Saunders  Company 


PRINTED    IN    AMERICA 

PRESS    OF 

W.     B.     SAUNDERS     COMPANV 

PHILADELPHIA 


PREFACE  TO   THE  SECOND   EDITION 


The  generous  reception  accorded  the  j&rst  edition  of  this 
manual  justifies  the  inference  that  a  purely  clinical  presenta- 
tion of  mental  disease  fulfils  a  distinct  want.  The  practising 
physician  has  too  often  looked  upon  insanity  as  a  subject  un- 
attractive and  obscure,  difficult  and  abstruse,  and  with  which, 
because  of  the  speculative  and  metaphysical  character  of  its 
theories  and  explanations,  he  has  no  immediate  concern.  The 
truth  is,  however,  that  when  viewed  from  the  standpoint  of 
internal  medicine  it  is  brought  into  close  and  intimate  rela- 
tions with  the  latter.  This  becomes  especially  evident  when 
we  realize  that  many  cases  of  mental  disease  have  their  origin 
in  infections  and  intoxications,  while  others  present  problems 
which  are  essentially  those  of  disorders  of  metabohsm.  Many 
of  the  latter  have  to  do  \\dth  profound  nutritional  disturbances 
which  have  their  origin  in  defensive  reactions  of  the  organism 
to  intoxications.  Such  intoxications  may  arise  from  with- 
out or,  it  may  be,  from  within  the  organism.  Among  the  latter 
are  toxic  states  due  to  abnormahties  of  the  various  glands  of 
internal  secretion  or  of  other  structures.  In  other  cases  of 
mental  disease,  again,  the  physician  has  to  do  with  aberrancies 
and  arrests  of  development,  -^dth  pecuharities  of  structure  and 
mental  organization  often  hereditary;  and  in  each  of  these 
there  are,  again,  the  added  and  largely  unsolved  problems  of 
toxic  metabohsm.  Finally,  in  given  instances,  the  mental 
symptoms  are  in  relation  with  gross  visceral  or  bodily  disease. 
In  short,  the  more  we  study  insanity,  the  more  we  become 

9 


10  PREFACE 

convinced  of  the  importance  of  bringing  the  subject  into  the 
closest  possible  relations  with  internal  medicine. 

This  edition,  like  the  first,  is  based  upon  the  annual  course 
of  lectures  delivered  by  the  author  at  the  Jefferson  Medical 
College,  and  has  been  prepared  from  a  purely  practical  point 
of  view.  In  the  classification,  general  arrangement,  and  de- 
scriptions the  author  has  endeavored  to  present  the  subject 
in  a  simple  and  yet  thorough  manner,  and,  at  the  same  time, 
to  keep  the  volume  within  the  limits  of  a  convenient  manual. 
It  is  the  general  practitioner,  the  family  physician,  who  sees 
the  patient  first,  and  he  should  be  sufficiently  informed  to  be 
able  to  recognize  mental  diseases  in  their  early  stages.  He 
should  know  what  to  do  under  given  conditions;  how  the  pa- 
tient should  be  treated  in  his  own  home  or  elsewhere  outside 
of  an  institution  should  this  be  practicable;  and  when  to  com- 
mit and  when  not  to  commit  a  patient  to  an  asylum. 

In  the  present  edition  the  various  sections  have  been  ex- 
panded so  as  to  include,  as  in  the  instances  of  dementia  praecox 
and  of  paresis,  the  more  recent  views  in  regard  to  pathology 
and  treatment;  in  the  case  of  dementia  prsecox  the  important 
and  interesting  results  of  Fauser  and  others  on  the  genesis 
and  pathology  of  the  affection  have  been  incorporated;  in  the 
case  of  paresis  the  advance  in  pathology  and  the  moot  ques- 
tion of  treatment  have  received  full  consideration.  The  chap- 
ter on  the  psychologic  interpretation  of  the  symptoms  has 
been  enlarged  and  in  part  rewritten,  as  have  also  various 
sections  on  treatment.  The  volume,  as  a  whole,  has  been 
thoroughly  revised,  and,  as  in  the  first  edition,  emphasis  has 
been  laid  upon  the  purely  clinical  and  practical  features. 

F.  X.  D. 

1719  Walnut  St.,  Phila.,  Pa. 
November,  1917. 


PREFACE 


Realizing  the  urgent  needs  of  the  medical  student  and  of  the 
practising  physician,  this  book,  which  is  based  upon  the  annual 
course  of  lectures  delivered  by  the  author  at  the  Jefferson 
Medical  College,  has  been  prepared  from  a  purely  practical 
point  of  view.  In  the  classification,  general  arrangement  and 
descriptions,  the  author  has  endeavored  to  present  the  sub- 
ject in  a  simple  and  yet  thorough  manner,  and,  at  the  same 
time,  to  keep  the  volume  within  the  limits  of  a  convenient 
manual.  Emphasis  has  been  laid  upon  the  clinical  pictures 
presented,  upon  prognosis,  and  upon  treatment.  It  is  the 
general  practitioner,  the  family  physician,  who  sees  the  pa- 
tient first,  and  he  should  be  sufficiently  informed  to  be  able 
to  recognize  mental  diseases  in  their  early  stages.  He  should 
know  what  to  do  under  given  conditions,  when  to  commit  and 
when  not  to  commit  a  patient  to  an  asylum,  and  how  the  patient 
should  be  treated  in  his  own  home  or  elsewhere  outside  of  an 
institution  when  this  is  practicable. 

In  view  of  the  recrudescence  within  recent  years  of  specula- 
tive and  metaphysical  psychiatry,  it  may  seem  an  act  of  temer- 
ity to  present  the  subject  from  a  clinical  point  of  view,  and  to 
restate  the  fact  which  it  took  our  ancestors  so  long  to  acquire, 
namely,  that  the  insane  man  is  a  sick  man  and  requires  a  sick 
man's  care.  To  the  author,  however,  this  seems  a  pressing 
need.     The   psychologic   interpretation   of   the   symptoms   of 

insanity,  aUke  interesting  and  fascinating,  is  presented,  though 

11 


12  PREFACE 

briefly,  in  a  special  part  of  this  volume,  and  the  author  trusts 
that  this  presentation  will  prove  to  be  lucid  and  also  adequate 
to  the  needs  of  the  student  and  practitioner.  Our  knowledge 
of  mental  diseases  will  doubtless  advance  in  two  parallel 
directions:  namely,  that  of  internal  medicine  and  that  of  psy- 
chologic interpretation.  To  the  practising  physician,  to  the 
needs  of  state  medicine,  of  public  hygiene  and  prevention,  that 
of  internal  medicine  will  ever  prove  the  most  important. 

F.  X.  D. 

1719  Walnut  St.,  Phila.,  Pa. 


CONTENTS 


PART  I 
CHAPTER  I 

PAGE 

Introduction.     Definitions 17 

CHAPTER  II 

Classification 26 

CHAPTER  III 

Group  I — Delirium,  Confusion,  Stupor ; 34 

Simple  Febrile  Delirium 35 

Specific  Febrile  Delirium 39 

Afebrile  Delirium 45 

Confusion , 49 

Passive  Confusion 56 

Stupor 56 

Incomplete  Stupor 60 

CHAPTER  IV 

Group   II — Melancholia,    Mania,    Circular   Insanity    (Melan- 
cholia-mania; Manic-depressive  Insanity) 62 

Melancholia 64 

Melancholia  with  Agitation 74 

Hypomelancholia 76 

Melancholia  without  Delusions 78 

MelanchoUa  with  Stupor 79 

Mania 81 

Hypomania 93 

Circular  Insanity 99 

The  Prognosis  of  Manic-depressive  Insanity  in  General 101 

CHAPTER    V 

Group  III — The  Heboid-paranoid  Affections  (Dementia  Precox; 

Paranoia) 108 

Insanity  of  Adolescence,  Dementia  Prsecox 113 

Distinguishing  Features  of  the  Simple  or  Hebephrenic  Form  125 

Distinguishing  Features  of  the  Catatonic  Form 126 

Distinguishing  Features  of  the  Paranoid  Form 127 

13 


14  CONTENTS 

PAGE 

Paranoia 138 

Paranoia  Hallucinatoria 143 

Hypochondriacal  Form 152 

Self-accusatory  Form 152 

Mystic  Form 154 

Paranoia  Simplex 159 

CHAPTER    VI 

Group  IV — The  Neurasthenic-neuropathic  Disorders  (Psych- 
asthenia)  175 

CHAPTER    VII 

Group  V — The  Dementias 202 


PART  II 

CHAPTER  I 

The  Clinical  Forms  of  Mental  Disease  Related  to  the  Somatic 

Affections 206 

The  Infections 207 

Sj-philis 207 

Tuberculosis 208 

Malaria 209 

Pellagra 210 

Rheumatic  Fever 211 

The  Intoxications 212 

Alcoholism  and  the  Alcoholic  Insanities 212 

Chronic  >\lcoholism 214 

Alcoholic  Delirium  (Delirium  Tremens) 216 

AlcohoUc  Confusion  (Alcoholic  Confusional  Insanity) 218 

Alcoholic  Paranoia 220 

AlcohoUc  Dementia 223 

Plumbism  and  the  Insanities  Due  to  Lead 224 

Morphinism 227 

Cocainism 233 

Intoxications  by  Chloral  and  Other  Drugs 236 

Disorders  of  Metabolism 237 

Diabetes 238 

Gout 240 

Adiposis 240 

The  Visceral  Diseases 241 

Diseases  of  the  Ductless  Glands 243 


CONTENTS  15 

-PAGE 

Diseases  of  the  Nervous  System 247 

Functional  Nervous  Diseases 247 

Epilepsy 247 

Hysteria 254 

Chorea 265 

Paralysis  Agitans 266 

Organic  Nervous  Diseases 266 

Paresis 266 

Cerebral  S3T)hilis 310 

Multiple  Cerebrospinal  Sclerosis 312 

Arteriosclerosis 312 

Hemorrhage,  Embolism,  and  Thrombosis 314 

Brain  Tmnor  and  Brain  Abscess 315 

Tabes 31S 

Tratuna 321 

Pregnancy,  Parturition,  the  Puerperium,  Lactation 324 

CHAPTER  II 

Mental  Diseases  as  Related  to  Age 330 

Insanity  in  Childhood 330 

Idiocy  and  Imbecility 333 

Morphologic  Idiocies 334 

Pathologic  Idiocies 335 

Cretinism 336 

Amaurotic  Family  Idiocy. 338 

Adolescence 343 

Early  Adult  Age 343 

Mature  Adult  Age 344 

Middle  Age 344 

Old  Age 345 

CHAPTER  III 

Mental  Diseases  not  Ordinarily  Included  Under  Insanity...  352 

Borderland  Manic  and  Paranoid  States  (The  Mattoids) 352 

States  of  High-grade  Deficiency;  Moral  Deficiency;  Criminality 

(The  Morons) 354 

Sexual  Abnormalities 358 

Hypochondria 363  ■ 

CHAPTER  IV 

Insanity  by  Contagion 377 


PART  III 


CHAPTER  I 

The  Psychologic  Interpretation  of  the  Symptoms 383 


16  CONTENTS 

PART  IV 

CHAPTER  I  PAQK 

Treatment 412 

Prevention 412 

Extramural  Treatment 417 

Intramural  Treatment 445 

Index 459 


A  CLINICAL  MANUAL 


OF 


MENTAL  DISEASES 


PART  I 

CHAPTER  I 

INTRODUCTION.     DEFINITIONS 

The  position  of  insanity,  both  as  regards  the  community  and 
the  profession  of  medicine,  has  always  been  somewhat  pecuhar. 
Long  unrecognized  as  deahng  with  diseased  states,  it  was 
looked  upon  as  something  apart  from  medicine,  and  up  to  quite 
recent  times  it  was  the  subject  of  religious  and  superstitious 
interpretation.  All  ancient  peoples — the  Egyptians,  the  He- 
brews, the  early  Greeks — looked  upon  the  insane  as  persons 
possessed  of  evil  spirits,  as  the  victims  of  demoniac  posses- 
sion, or,  more  rarely,  as  the  inspired  instruments  of  the  Deity. 
These  crude  and  fearsome  explanations  were  singularly  like 
those  of  the  barbarous  peoples  of  our  own  day.  In  the  rise  of 
the  Greek,  the  Alexandrian,  and  the  Roman  civilizations, 
superstition  gradually  lost  ground  and  various  scientific  ex- 
planations were  adopted.  The  insane  were  looked  upon  as 
persons  who  were  ill,  and  they  were  frequently  treated  by  drugs, 
baths,  exercise,  and  other  hygienic  measures.  However, 
beginning  with  about  the  second  or  third  centuries  of  the 
Christian  era,  a  great  retrogression  took  place.     Theories  of 

2  17 


18  MENTAL    DISEASES 

demoniac  possession,  of  sorcery,  and  witchcraft  again  held  sway, 
and  the  insane  were  subjected  to  neglect,  cruelty,  and  torture. 
This  attitude  of  superstition  continued  throughout  the  Middle 
Ages,  and,  indeed,  until  long  after  the  dawn  of  the  Renaissance. 
It  was  not  until  the  eighteenth  century  that  any  marked  ad- 
vance was  made.  The  insane  were  still  confined  in  dungeons, 
badly  fed,  clothed  in  rags,  and  weighted  down  with  chains. 
Various  places  for  the  custody  and  care  of  the  insane  were, 
however,  gradually  established;  for  instance,  in  Rome,  in 
Bethlehem,  England,  in  Ghent  and  Gheel  in  Belgium,  and  in 
the  Hotel  Dieu  in  Paris;  but  no  real  provision  was  made  for 
their  humane  care  until  the  latter  part  of  the  eighteenth  cen- 
tury, when  Pinel,  in  France,  Tuke,  in  England,  and  Benjamin 
Rush,  in  America,  made  the  first  real  advances.  In  1793  Philip 
Pinel  was  appointed  physician  to  the  Bicctre,  and  substituted 
a  system  of  non-restraint  and  humane  treatment  for  blows 
and  punishments.  At  the  same  time  that  Pinel  was  making 
these  great  strides  in  France,  William  Tuke,  a  member  of  the 
Society  of  Friends,  who  was  not  even  a  physician,  began  simi- 
lar reforms  in  England.  He  established  a  retreat  or  asylum 
at  York,  which  was  opened  in  1796,  and  in  which  a  rational 
care  and  humanity  were  likewise  the  guiding  principles.  Subse- 
quently these  methods,  though  slowly,  were  adopted  elsewhere. 
Scientific  conceptions  as  to  the  nature  of  insanity  were  like- 
wise very  slow  in  developing.  The  essentially  sinful  character 
of  insanity,  advocated  by  Stahl  in  the  early  eighteenth  century, 
still  found  its  advocate  in  the  person  of  Heinroth  in  the  early 
nineteenth.  Little  by  little,  however,  metaphysic  and  psy- 
chologic explanations  began  to  take  the  place  of  religious 
theories.  The  latter  were  finally  definitely  abandoned,  and 
physicians  began  to  reason  about  insanity  in  a  philosophic, 
though  purely  speculative  way;  science  had  not  yet  made  pos- 
sible the  framing  of  views  based  upon  fact.     Physicians  were 


INTRODUCTION.      DEFINITIONS  19 

slow  to  realize  the  essential  truth  that  the  insane  man  is,  in 
reality,  a  sick  man,  and  that  his  symptoms  must  be  studied 
just  as  we  study  those  of  other  forms  of  disease.  Insanity,  of 
course,  imphes  disease,  organic  or  functional,  just  as  do  other 
abnormal  manifestations.  Further,  this  disease  is  of  the 
material  organism,  either  of  the  organism  as  a  whole  or  of  some 
special  structure.  It  may  be  the  direct  outcome  of  some  general 
affection,  of  a  disease  of  the  brain  or  of  a  disease  of  other  viscera. 
The  symptoms  of  insanity  are  always  those  of  disturbed 
cerebral  action.  They  may  be,  indeed,  most  frequently  are, 
attended  by  few  or  no  demonstrable  changes  in  the  brain,  its 
membranes,  or  its  vessels,  and  it  is  not  surprising  that  this 
should  be  so.  Insanity  is  at  times  purely  symptomatic  of 
bodily  or  visceral  disease,  and  the  mental  symptoms  may  be 
those  merely  of  exhaustion  or  may  result  from  the  action  of 
poisons  circulating  in  the  blood.  In  either  case,  the  changes 
in  the  nerve  tissue  are  probably  both  shght  and  evanescent. 
That  the  nervous  system  can  be  profoimdly  influenced  by  poi- 
sons which  leave  no  changes  in  their  wake  is  shoT^n  by  the 
action  of  various  drugs,  narcotics,  and  stimulants,  which 
modify  nervous  function  and  yet  cause  no  change  in  nerve  cell 
or  fiber  that  can  be  demonstrated  under  the  microscope.  Simi- 
larly, the  mental  symptoms  caused  by  uremia,  by  thyroid  in- 
toxication, or  by  the  toxins  of  infection,  apparently  produce 
changes  so  slight  as  to  be  beyond  our  present  abilitj^  to  rec- 
ognize them,  or  so  slight  as  to  be  effaced  by  the  act  of  death 
itseK.  That  dendrites,  collaterals,  and  the  cell  body  should 
respond  to  the  action  of  toxins,  and  that  various  disturbances 
of  association,  of  sensation,  of  the  elimination  of  impulses,  of 
the  flow  of  ideas,  in  short,  of  any  or  all  of  the  manifold  func- 
tions of  the  brain  should  ensue,  can  readily  be  conceived. 
That  this  is  not  all  a  matter  of  speculation  is  shown  by  what 
is  known  of  the  action  of  such  poisons  as  alcohol.     Berkley, 


20  MENTAL    DISEASES 

Andriezen,  and  others  have  demonstrated  changes  both  in  the 
cell  body  and  the  cell  processes  which  result  from  the  ingestion 
of  large  amounts  of  alcohol;  it  would  appear  that  dendrites 
and  collaterals  are  actually  destroyed  or  corroded  by  the  poi- 
son. It  would  seem  as  though  other  poisons  likewise  act  upon 
these  delicate  structures — the  minute  threads  of  protoplasm 
represented  by  the  collaterals,  the  dendrites,  and  the  neuro- 
fibrils— but  that  in  most  cases  the  action  is  less  destructive  and 
induces  merely  changes  of  function  rather  than  changes  of 
structure. 

In  a  small  number  of  cases  of  mental  disease,  gross  or  micro- 
scopic lesions  are  present,  such  as  changes  in  the  nerve  tissue, 
disease  of  the  blood-vessels,  of  the  membranes,  chronic  inflam- 
matory changes,  softening,  abscesses,  and  tumors. 

In  other  patients  unusual  morphologic  factors  are  noted. 
These  may  pertain  to  the  skull,  to  various  features,  such  as  the 
ears,  palate,  and  teeth,  to  the  limbs,  or  to  the  body.  These 
morphologic  peculiarities  are  surface  indications  of  profound 
departures  from  normal  growth  and  development  of  the  organ- 
ism as  a  whole.  Most  frequently  they  are  evidences  of  arrest, 
but  at  other  times  of  pathologic  deviations.  How  significant 
these  facts  are  ^\dll  become  more  apparent  as  we  proceed  in 
our  studies. 

The  wide  scope  of  the  subject  and  the  relation  which  insanity 
bears  to  other  states  precludes  a  simple  and  formal  definition. 
This  becomes  evident  as  soon  as  a  definition  is  attempted.  In 
general  terms,  insanity  consists  of  abnormal  mental  action,  and 
yet  a  brief  consideration  convinces  us  that  this  definition  is  too 
broad;  it  includes  much  more  than  is  ordinarily  understood  by 
insanity.  Thus,  it  includes  the  delirium  accompanying  an  attack 
of  measles;  it  includes  the  various  forms  of  acute  intoxication, 
for  example,  by  alcohol,  morphin,  chloral,  etc.;  it  includes  the 
disorders  of  sleep,  dreams,  trance,  and  somnambuUsm;    and 


INTRODUCTION.      DEFINITIONS  21 

these  various  manifestations  of  disturbed  cerebral  action  can 
certainly  not  be  classified  among  the  insanities.  To  the  medi- 
cal mind  a  formal  definition  of  insanity  is  neither  necessary  nor 
possible.  However,  a  definition  is  sometimes  exacted  on  the 
witness  stand.  Under  these  circumstances,  insanity  may  be 
defined  as  a  diseased  state  in  which  there  is  a  more  or  less  per- 
sistent departure  from  the  normal  manner  of  thinking,  acting,  and 
feeling.  If  occasion  demands,  it  is  well  to  add  that  ordinary 
febrile  delirium,  intoxication,  and  sleep  disturbances  are  not 
included. 

The  term  "alienation"  is  often  used  in  the  same  sense  as  in- 
sanity. However,  it  embraces,  besides  insanity,  also  idiocy 
and  imbeciUty,  which  are  not,  properly  speaking,  insanities. 
Idiocy  and  imbecility  are  quantitative  defects;  they  imply  an 
original  deficiency  of  mind,  while  insanity  is  essentially  a 
qualitative  affection. 

Idiocy  and  imbecility  are  related  conditions.  In  idiocy  the 
mental  deficiency  is  the  result  either  of  disease  or  arrested  de- 
velopment previous  to,  at  the  time  of,  or  within  a  very  few 
years  following  birth.  Imbecility  deals  with  a  mental  de- 
ficiency which  is  less  pronounced  in  degree,  is  not  evident  at 
birth  or  shortly  after  birth,  and  only  becomes  apparent  as  the 
child  grows  older  or  as  it  approaches  puberty  or  adult  life.  The 
law  takes  cognizance  of  these  facts,  and  has  defined  an  idiot 
as  "one  who  is  born  without  mind,"  and  an  imbecile  as  "an 
adult  with  the  mind  of  a  child."  Both  of  these  definitions 
are,  of  course,  excessive,  but  they  nevertheless  embody  the 
truth.  The  idiot  is  one  in  whom  the  mental  loss  is  congenital 
or  nearly  so.  The  imbecile  is  one  in  whom  the  symptoms  of 
mental  arrest  make  their  appearance  later. 

In  order  to  discuss  intelligently  the  symptoms  presented  by 
the  insane,  it  is  necessary  that  we  should  have  clear  conceptions 
of  some  of  the  terms  by  which  these  symptoms  are  designated. 


22  MENTAL    DISEASES 

Fortunately  their  number  is  not  large  and  they  are  not  difficult 
of  comprehension.  Many  patients  present  what  are  termed 
"hallucinations."  A  hallucination  is  roughly  defined  as  a  sensa- 
tion without  an  object.  It  is  perhaps  best  explained  by  a  few 
illustrations.  A  patient  hears  a  bell  ringing,  when,  in  fact,  no 
bell  is  ringing,  and  no  other  sound  vibrations  have  been  present 
which  could  give  rise  to  the  same  or  similar  sensations;  or 
the  patient  believes  that  he  sees  some  object — e.  g.,  an  animal,  a 
human  figure — when  no  such  object  is  present.  In  other  words, 
a  hallucination  is  a  sensation  which  arises  spontaneously  in  the 
mind  without  there  being  any  object  in  the  external  world  to 
excite  that  sensation.  Hallucinations  may  affect  any  of  the 
senses.  Thus,  we  may  have  auditory  and  visual  hallucina- 
tions, hallucinations  of  taste  and  smell,  hallucinations  of  touch, 
or  there  may  be  various  somatic  hallucinations,  that  is,  ob- 
scure sensations  referred  to  various  parts  of  the  body  or  to 
various  viscera. 

Some  patients  present  what  are  termed  "illusions."  An  illu- 
sion is  a  perception  which  is  misinterpreted.  Thus,  the  patient  sees 
an  object,  for  instance,  a  chair,  and  mistakes  it  for  some  other 
object,  it  may  be  an  animal;  or,  he  hears  the  ticking  of  a  clock, 
and  mistakes  the  sounds  for  articulate  words  or  sentences. 
He  mistakes  a  curtain  cord  for  a  snake,  or  a  rug  upon  the  floor 
for  a  wild  beast.  Contrary  to  hallucinations,  in  an  illusion  an 
object  is  really  present  in  the  external  world  and  an  impression 
is  really  made  upon  the  senses,  but  the  object  is  incorrectly 
interpreted.  A  mistake  in  perception  may,  of  course,  be  due  to 
a  defect  or  peculiarity  of  a  sensory  organ,  such  as  the  eye,  but 
such  a  mistake  does  not  constitute  an  illusion  in  the  sense 
which  here  concerns  us.  In  an  illusion,  as  the  term  is  here 
employed,  the  object  perceived  is  not  properly  apprehended 
and  the  impression  is  not  properly  correlated  with  previous 
impressions  or  experiences.     Further,   an  illusion  may,   and 


INTRODUCTION.       DEFINITIONS  23 

frequently  does,  excite  or  become  associated  with  other  sen- 
sations, or  it  may  evoke  thoughts  and  feelings  not  normally 
excited  by  the  object  in  question.  Illusions  and  hallucinations, 
it  should  be  added,  both  play  an  important  role  in  the  symp- 
tomatology of  insanity.  They  are  common  symptoms  in  a 
large  number  of  diseases. 

Patients  also  present  what  are  termed  "delusions."  A  delusion 
may  be  roughly  defined  as  a  false  belief,  but  it  is  seen  at  once 
that  such  a  definition,  without  qualification,  embraces  far  more 
than  is  intended.  Persons  holding  opposite  religious  views 
could  reasonably  accuse  each  other  of  holding  false  beliefs,  but 
not  of  possessing  insane  delusions.  This  is  also  true  of  other 
beliefs,  political  and  scientific,  which  men  may  hold.  It  be- 
comes necessary,  therefore,  to  qualify  this  definition,  and  this 
we  may  do  as  follows:  An  insane  delusion  is  a  false  belief  con- 
cerning which  the  patient  is  unable  to  accept  evidence,  such  as  is 
accepted  by  ordinary  men  or  by  normal  minds.  It  is  the  inability 
to  accept  the  proffered  evidence  which  gives  rise  to  the  delusion. 
Thus,  a  patient  who  believes  that  he  no  longer  has  a  mouth, 
and,  in  spite  of  all  demonstrations  to  the  contrary,  persists  in 
his  belief,  is  possessed  of  a  delusion.  A  man  who  believes  that 
all  his  bones  are  broken  or  that  he  is  possessed  of  the  strength 
to  move  mountains,  and  who  is  incapable  of  accepting  the 
proof  offered  that  he  is  in  error,  is,  of  course,  the  victim  of  de- 
lusions. It  is  this  inabihty  to  accept  evidence  which  is  so 
striking  a  factor  in  the  delusion  of  the  unpardonable  sin  in 
melancholia,  in  the  delusion  of  persecution  in  paranoia,  in  the 
delusions  of  grandeur  in  paresis. 

Delusions  are  variously  spoken  of  as  systematized  and  unsys- 
tematized. A  systematized  delusion  is  one  which  has  a  logical 
structure,  i.  e.,  the  various  parts  of  the  delusion  bear  a  coherent 
or  logical  relation  to  each  other;  thus,  a  man  may  believe  that 
his  neighbors  have  made  holes  in  the  walls  of  his  house  and  that 


24  MENTAL    DISEASES 

through  these  holes  they  shout  curses  or  abuses,  or  he  may 
believe  that  his  neighbors  have  entered  into  a  conspiracy  to 
injure  him;  again,  he  may  believe  that  he  is  possessed  of  un- 
usual powers,  that  he  is  a  person  of  unusual  consequence,  and 
that  he  is  destined  to  perform  great  deeds  and  great  missions. 
As  a  rule,  though  not  always,  systematized  delusions  do  not 
present  much  complexity;  they  are  relatively  simple,  and  the 
various  parts  of  the  behef  are  always  in  relation  with  each  other. 
In  unsystematized  delusions  the  reverse  obtains.  -All  evidence  of 
a  logical  structure  is  wanting.  Unsystematized  delusions  are 
seen  typically  in  delirium  and  confusion;  here  delusions  which 
are  fragmentary,  fleeting,  and  unrelated  crowd  into  the  patient's 
mind.    At  no  time  is  a  coherent  relation  apparent. 

Delusions  are  also  spoken  of  as  expansive  or  depressive. 
An  expansive  delusion  is  one  which  embodies  the  idea  of  grand- 
eur, beauty,  perfection,  power,  wealth,  or  other  quality  of  ex- 
cellence or  greatness  in  the  patient.  Thus,  a  man  believes  that 
he  is  Napoleon;  that  all  people  are  subject  to  his  will;  that  he 
owns  all  the  ships  upon  the  sea;  that  he  is  about  to  marry  the 
queen;  that  he  owtis  bilUons  upon  billions;  that  he  has  the 
finest  voice  that  was  ever  heard;  that  his  strength  is  super- 
human; that  he  is  possessed  of  occult  powers  or  of  some  other 
mysterious  quahty,  indicative  either  of  physical  or  mental 
greatness. 

A  depressive  delusion,  on  the  other  hand,  is  one  which  embod- 
ies the  idea  of  belittlement,  of  unworthiness,  of  persecution,  of 
physical  or  mental  wretchedness,  of  poverty,  or  of  other  quali- 
ties indicative  of  suffering.  Depressive  delusions  hiay  be  of 
two  kinds.  They  may  relate,  first,  to  the  spiritual  side  of  man, 
and  may  embody  ideas  of  moral  unworthiness  and  self-accusa- 
tion, and  may,  under  certain  circumstances,  give  rise  to  the 
delusion  of  the  "unpardonable  sin."  Again,  they  may  deal 
merely  with  the  body;  that  is,  the  patient  may  believe  that  he 


INTRODUCTION.      DEFINITIONS  25 

is  ill,  that  his  body  is  diseased,  that  he  no  longer  has  a  mouth, 
that  he  has  a  snake  in  his  stomach,  that  his  viscera  have  been 
removed,  or  that  he  has  some  hopeless  physical  ailment.  Such 
delusions  may  be  spoken  of  as  somatic  or  as  hypochondriac. 
Very  frequently  spiritual  and  somatic  delusions  exist  in  the  same 
patient,  and  often  it  is  not  possible  to  separate  them,  ideas  of 
spiritual  unworthiness  and  bodily  disease  being  intermingled. 
We  should  remember,  also,  that  depressive  delusions  may  relate 
neither  to  the  spiritual  nor  physical  makeup  of  the  patient, 
but  may  assume  the  form  of  delusions  of  persecution. 

Two  terms  which  are  frequently  used  in  speaking  of  the  insane 
require  a  moment's  attention.  They  are  neurasthenic  and  neu- 
ropathic. The  word  "neurasthenia"  literally  means  without 
nervous  strength,  and  a  neurasthenic  patient  is  one  presenting 
a  group  of  symptoms  indicative  of  exhaustion  and  chronic 
fatigue.  Neurasthenia  deals  essentially  with  functional  con- 
ditions. 

The  word  "neuropathic,"  on  the  other  hand,  is  applied  to  those 
fundamental  deficiencies  and  aberrations  of  the  nervous  system 
which  predispose  it  to  disease,  or  which  of  themselves  entail 
disease  and  degeneration.  Neuropathy  has  its  origin  in  basic 
morphologic  and  functional  deviations  and  weaknesses,  and, 
as  might  be  supposed,  it  is  largely  hereditary  and  plays  an  im- 
portant role  in  mental  disease.  The  changes  present  in  neuro- 
pathic states,  as  a  rule,  embrace  the  organism  as  a  whole.  Some 
peculiarity  of  structure,  which  has  its  origin  in  aberrant  and 
defective  development,  in  the  ductless  glands,  in  vascular  supply, 
or  in  some  other  unknown  quality  which  favors  degeneration  of 
the  nervous  system,  is  transmitted  from  parent  to  child,  and 
it  is  this  tendency  to  degeneration  which  is  termed  neuropathic. 

Other  terms  used  in  the  description  of  mental  symptoms  will 
be  considered  and  defined  as  occasion  arises. 


CHAPTER  II 

CLASSIFICATION 

Pathology  has  as  yet  so  little  to  offer  that  we  must  content 
ourselves  with  a  purely  clinical  interpretation  of  insanity.  A 
chnical  interpretation  is  not  only  of  practical  value,  but  it  is 
also  interesting  and  scientific.  The  clinical  interpretation  of  a 
disease  means  literally  its  bedside  interpretation,  and  into  such 
an  interpretation  there  enters  every  fact  at  our  disposal,  near 
or  remote — not  only  the  symptoms  presented  by  the  patient, 
not  only  his  family  history  and  his  personal  history,  not  only 
his  sex,  his  age,  or  epoch  of  life,  but  all  that  we  know  of  the 
changes  in  the  tissues,  and  of  the  course,  the  duration,  and 
the  prognosis  of  the  disease  in  similar  cases.  In  attempting 
a  classification  of  insanity  from  the  clinical  standpoint,  there- 
fore, we  are  guided  not  by  a  single  series  of  facts  such  as  are 
presented  by  etiology,  or  by  symptoms,  or  by  the  scanty 
facts  of  pathology,  but  by  all  of  these  and  others  combined. 
It  presupposes  that  we  approach  the  subject  from  all  pos- 
sible points  of  view,  that  we  weigh  all  facts,  no  matter  in 
which  category  they  are  found,  that  we  explore  all  of  the  con- 
verging avenues  of  truth — in  short,  that  we  take  into  account 
everything  that  enters  into  the  natural  history  of  the  disease 
we  are  about  to  study.  Such  a  method  is  not  only  philosophic 
and  scientific,  but  is  necessitated  by  the  condition  of  our  knowl- 
edge of  the  subject,  and  it  gives  rise  to  clear  and  logical  con- 
ceptions in  a  field  where  confusion  and  imcertainty  too  often 
prevail. 

26 


CLASSIFICATION  27 

I  have  long  come  to  the  conclusion  that  insanity  must,  as 
far  as  possible,  be  approached  from  the  standpoint  of  practical 
medicine.  Indeed,  it  has  seemed  to  me  most  natural  to  begin 
the  study  of  mental  disorders  with  the  affections  with  which 
the  general  practitioner  first  comes  in  contact.  For  instance, 
no  graduate  of  medicine  practices  long  before  he  comes  in  con- 
tact with  such  an  elementary  phenomenon  as  delirium.  A  child 
has  an  attack  of  fever,  and  the  physician  observes  that  it  is 
confused,  that  it  does  not  recognize  its  surroundings,  that  it 
cries  out,  that  it  shrinks,  struggles,  acts  as  though  it  heard 
strange  sounds  and  saw  strange  objects.  At  the  same  time,  its 
restlessness,  its  cries,  its  broken  and  hurried  words  indicate  that 
the  cerebral  activity,  though  perverted,  is  abnormally  aroused. 
This  picture,  so  familiar,  is  the  picture  of  simple  delirium. 
There  are  present  illusions,  hallucinations,  confusion  and  hurry 
of  thought,  fleeting  and  fragmentary  delusions,  incoherence. 
We  soon  find  that  these  elements  are  present  in  every  form  of 
delirium,  no  matter  what  its  origin,  and  our  first  logical  con- 
clusion is  that  in  these  essential  particulars  all  of  the  deliria  are 
alike.  It  is  perfectly  true  that  some  of  the  deliria  present 
special  features  dependent  upon  their  causation,  as  in  alco- 
holic deUrium  in  which  visual  hallucinations  predominate,  and 
yet  the  fundamental  symptoms  are  always  the  same.  This 
is  the  case  whether  the  delirium  occurs  in  a  young  or  an  old 
person,  whether  it  be  mild  or  whether  it  be  severe. 

Delirium  is  essentially  an  acute  mental  confusion  of  rela- 
tively short  duration — a  few  hours,  a  few  days,  or,  at  most,  a 
week  or  two.  Naturally,  the  morbid  state  which  is  most  closely 
alhed  to  delirium  is  one  in  which  confusion  is  less  active  but 
more  prolonged.  Such  a  state  is  found  in  the  prolonged  con- 
fusion which  every  now  and  then  comes  on  in  infectious  dis- 
eases after  fever  has  subsided.    It  is  seen  typically  in  the  con- 


28  MENTAL    DISEASES 

fusional  insanity  following  typhoid  fever,  influenza,  erysip- 
elas, acute  articular  rheumatism,  the  puerperium,  profound  ex- 
haustion, trauma,  surgical  shock,  etc.  Into  its  causation,  there 
enter  especially  two  factors:  first,  the  toxins  of  infection  or 
other  poisons,  and,  second,  profound  and  persistent  exhaus- 
tion. Its  symptoms  do  not  differ  in  any  essential  particulars 
from  those  of  delirium,  save  that  they  are  less  acute  and  the 
course  of  the  disease  far  more  prolonged.  In  confusional  in- 
sanity— the  amentia  of  Meynert,  the  Verwirrtheit  of  other 
German  writers — there  is  the  same  presence  of  hallucinations 
and  delusions,  the  same  marked  confusion  and  incoherence, 
but  cerebral  activity  is  never  roused  to  the  same  high  pitch, 
and,  while  delirium  lasts  from  a  few  hours  to  a  few  days  or  more, 
confusion  may  last  many  months.  The  various  forms  of  con- 
fusion are  closely  allied  to  each  other,  just  as  are  the  deliria, 
and  no  sharp  distinctions  can  be  drawn  between  them.  How- 
ever, special  forms  may  bear  the  impress  of  their  causation. 
Thus,  a  confusional  insanity  following  typhoid  fever  presents 
a  somewhat  different  clinical  picture  from  the  confusional 
insanity  of  alcohol-  or  lead-poisoning,  and  yet  in  all  essential 
particulars  they  are  the  same. 

Every  now  and  then  we  meet  with  cases  in  which  an  infection, 
poisoning,  or  profoundly  debilitating  cause  is  followed  by  men- 
tal confusion,  but  in  which  the  confusion  is  accompanied  with 
very  marked  dulness  and  hebetude,  and  in  which,  little  by  little, 
mental  obtusion  becomes  more  and  more  pronounced,  until 
finally  the  faculties  are  completely  in  abeyance.  Such  a  case 
forms  one  of  stupor  or  so-called  stuporous  insanity  or  acute 
dementia.  Simple  stupor,  as  is  well  known,  does  not  make  its 
appearance  suddenly.  Generally  there  is  a  prodromal  period 
of  several  days  or  weeks  during  which  the  patient  suffers  from 
more  or  less  marked  mental  confusion,  attended,  it  may  be, 


CLASSIFICATION  29 

with  excitement  or  with  depression.  As  in  the  beginning  of  con- 
fusional  insanity,  the  patient  at  first  suffers  from  insomnia,  is 
worried  and  afraid,  and  is  unable  to  think  clearly.  Soon  con- 
fusion makes  its  appearance.  There  is  loss  of  the  proper  appreci- 
ation of  the  surroundings.  As  in  ordinary  confusion,  the  patient 
believes  himself  to  be  in  a  strange  place  and  does  not  properly 
recognize  the  persons  about  him.  He  is  also  distinctly  hallucina- 
tory, and  up  to  this  point  the  case  resembles  one  of  confusional 
insanity  without  much  excitement.  Little  by  little  mental  ob- 
tusion, noticed  in  the  beginning,  becomes  more  and  more  marked, 
and  soon  the  loss  of  the  power  to  appreciate  the  surroundings  be- 
comes so  profound  that  the  patient  lies  motionless  in  bed, 
oblivious  to  everything  about  him.  There  is  now  no  longer 
confusion,  but  instead  a  more  or  less  complete  suspension  of 
mental  action — stupor. 

It  would  be  out  of  place  here  to  dwell  further  upon  the  symp- 
toms of  stupor.  I  wish  merely  to  emphasize  the  fact  that  con- 
fusion and  stupor  are  closely  related  clinical  forms.  It  is,  indeed, 
at  times  impossible  to  accurately  characterize  a  given  case.  In 
the  first  place,  stupor  may  occur  as  an  episode  of  confusional 
insanity;  and,  secondly,  cases  are  met  with  which  occupy  such 
an  intermediate  position  that  we  are  obUged  to  term  them 
cases  of  confusion  with  stupor  or  stuporous  confusion.  What 
is  true  of  the  interrelation  of  confusion  and  stupor  is  also  true, 
I  need  hardly  say,  of  the  interrelation  of  delirium  and  confusion. 
Every  now  and  then  it  happens  that  a  case  beginning  as  a  simple 
delirium  merges  into  one  of  confusion,  and  it  is  also  true  that 
during  the  course  of  a  confusional  insanity  episodes  of  more  or 
less  active  delirium  may  supervene.  Clearly,  delirium,  con- 
fusion and  stupor  are  closely  related  clinical  forms,  and  they 
may  be  considered  as  constituting  a  group  of  mental  affections 
by  themselves,  separate  and  distinct,  as  we  will  see,  from  other 


30  MENTAL    DISEASES 

mental  disorders.  I  will  not  here  deal  with  the  causes  of 
delirium,  confusion,  or  stupor.  A  sufficient  hint  is  afforded  us 
in  the  chnical  history.  We  have  at  once  suggested  to  our 
minds  the  action  of  the  bacteria,  of  bacterial  toxins,  and  of  other 
poisons  upon  the  cortex.  It  is  probable  that  in  deUrium  we 
have  especially  and  essentially  such  an  action,  while  in  con- 
fusion and  stupor  we  have  the  added  factors  of  exhaustion  and 
secondary  changes  in  metabolism. 

The  above  considerations  show  that  delirium,  confusion,  and 
stupor  are  closely  related  forms,  and  we  construct  of  them  the 
first  group  of  our  classification  of  mental  diseases.  As  pointed 
out,  they  are  more  or  less  characterized  by  the  presence  of 
hallucinations,  illusions,  unsystematized  delusions,  incoherence 
and  confusion.  As  our  studies  progress  we  will  learn,  in  addi- 
tion, two  important  facts:  first,  that  the  emotional  state, 
though  it  may  be  disturbed,  plays  only  a  secondary  role;  and  sec- 
ondly, that  heredity  is,  in  this  group,  of  subsidiary  importance. 

In  these  respects,  dehrium,  confusion,  and  stupor  differ 
radically  from  the  next  group  of  mental  diseases  to  be  consid- 
ered; namely,  melancholia,  mania,  and  circular  insanity.  Here 
the  emotional  state  dominates  the  entire  clinical  picture  and 
outweighs  all  other  symptoms.  Secondly,  the  affection,  whether 
it  be  mania  or  melancholia,  pursues  a  wave-like  course.  Heredity 
also  plays  a  most  important  role;  it  is  a  striking  factor  in  the  clin- 
ical history  of  the  great  majority  of  cases.  Further,  as  we  study 
these  affections,  we  will  recognize  that  they  are  closely  related  to 
each  other.  In  melancholia  the  patient  passes  through  a  phase  of 
emotional  depression;  in  mania,  through  a  phase  of  emotional  ex- 
altation, and  in  circular  insanity,  through  both  of  these  phases, 
one  after  the  other.  The  symptom  group  of  melancholia-mania 
differs,  of  course,  radically  from  that  of  delirium,  confusion,  and 
stupor.    We  have,  for  example,  in  the  phase  of  mania,  as  we  will 


CLASSIFICATION  31 

learn  farther  on,  an  expansive  emotional  state,  an  increased  ra- 
pidity in  the  elimination  of  ideas,  an  abnormal  increase  of  associ- 
ation, an  absence  of  hallucinations,  fleeting,  expansive  delusions; 
in  melancholia,  emotional  depression,  psychic  inhibition,  depres- 
sive delusions.  The  members  of  this  group  are  characterized, 
let  us  repeat,  by  a  dominant  emotional  state  and  by  a  wave- 
like course.  In  our  scheme  of  classification  they  constitute  the 
second  group.  Following  the  lead  of  Kraepelin,  we  may  speak 
of  them  collectively  as  manic-depressive  insanity.  Further, 
in  this  group,  the  tendency  is  to  recovery  from  individual  at- 
tacks, but  the  disease  tends  to  repeat  itself  in  recurring  waves. 

In  still  another  group  of  mental  diseases  we  have  to  deal 
with  affections  that  are  essentially  degenerative  in  their  nature. 
The  individuals  who  suffer  from  them  are  essentially  defective 
in  their  make-up,  physical  and  mental.  As  a  rule,  they  present 
no  symptoms  which  attract  attention  until  some  time  after 
puberty  has  been  passed  or  until  youth  or  adult  age  is  reached. 
The  individual  appears  to  be  able  to  adapt  himself  to  the  strains 
of  life  in  greater  or  less  degree  until  a  certain  period  of  his 
career,  when,  by  reason  of  his  defective  organization,  he  breaks 
down.  Among  the  younger  patients  this  gives  rise  to  the  various 
forms  of  juvenile  insanity;  among  the  older,  to  various  forms 
of  delusional  lunacy.  Following  Kraepelin,  it  has  been  the 
custom  to  group  the  juvenile  insanities  under  the  general  term 
of  "dementia  prsecox,"  while  the  delusional  lunacies  are  con- 
veniently embraced  under  the  term  "paranoia."  The  juvenile. 
insanities  and  the  delusional  lunacies  form  a  natural  group, 
and  may  be  classed  together  under  the  general  term  "the  heboid- 
paranoid  group." 

Melancholia-mania  and  the  heboid-paranoid  group  are 
affections  which  are  essentially  neuropathic  in  their  nature. 
Alhed  to  them  we  have  still  another  group,  also  neuropathic, 


32  MENTAL    DISEASES 

which  is  made  up  of  mental  disorders  in  which  neurasthenia 
and  neuropathy  together  play  the  essential  roles.  There  is 
here  neither  a  wave-like  course,  as  in  manic-depressive  insanity, 
nor  a  downward  or  degenerative  course,  as  in  the  heboid-para- 
noid  forms,  but  merely  a  symptom  group  characterized  chiefly 
by  weakness  and  defective  inhibition.  These  disorders  may 
manifest  themselves  in  the  form  of  abnormal  fears,  of  chronic 
indecision,  of  deficient  control  of  impulses,  or  of  deficient  will. 
To  this  group  the  term  "neurasthenic  insanities"  was  long  ago  ap- 
plied by  French  writers.  The  term  "neurasthenic-neuropathic" 
is  more  expressive,  though  perhaps  a  little  awkward.  Of  late 
years,  following  Janet,  it  has  been  the  custom  to  employ  the 
term  "psj^chasthenia,"  which  the  writer,  however,  regards  as 
open  to  objection,  inasmuch  as  the  expression  "soul  weakness" 
can  hardly  be  regarded  as  conveying  a  definite  conception. 
(See  Chapter  VI.) 

In  order  to  make  the  clinical  view  of  insanity  complete,  it  is 
necessary  to  add  still  a  fifth  group,  namely,  insanities  resulting 
from  simple  mental  loss,  i.  e.,  dementia.  Dementia  may  exist 
as  a  simple  and  uncomphcated  condition,  and  is  frequently 
seen  in  its  pure  and  typical  form  in  old  age. 

The  five  groups  of  mental  affections  above  enumerated  are 
fundamental   and   are   necessary   to   a   comprehensive   inter- 
pretation.    They  are  as  follows: 
I.  Delirium,  Confusion,  Stupor. 

II.  Melancholia,   Mania,   Circular  Insanity   (Melancholia- 
mania,  Manic-depressive  insanity). 

III.  The  Heboid-paranoid  Group  (Dementia  Praecox,  Para- 

noia). 

IV.  The     Neurasthenic-neuropathic     Disorders     (Psychas- 

thenia.) 
V.  The  Dementias. 


CLASSIFICATION  33 

In  the  course  of  our  studies  we  -^-ill  next  consider  insanity 
from  the  point  of  view  of  internal  medicine;  this  is  practically 
of  great  importance.  We  vnll  consider  the  relation  which 
insanity  bears  to  the  various  infectious  diseases,  to  the  intoxi- 
cations, to  the  disorders  of  metabohsm,  to  the  various  diseases 
of  the  viscera,  to  the  diseases  of  the  nervous  system,  and, 
lastly,  to  pregnancy,  the  puerperium,  and  lactation. 

We  T\-ill  further  study  the  subject  as  related  to  the  various 
epochs  of  life,  namely,  to  infancy,  puberty,  early  adult  age, 
mature  adult  age,  middle  age,  and  old  age. 

Finally,  we  will  consider  briefly  certain  mental  diseases  not 
usually  included  under  insanity,  and  also  insanity  by  contagion. 


CHAPTER  III 

GROUP   I— DELIRIUM,    CONFUSION,    STUPOR 

Delirium,  the  first  member  of  this  interesting  group,  occurs 
as  a  very  common  epiphenomenon  of  fevers,  infection,  intoxi- 
cation and  exhaustion.  It  is,  therefore,  a  condition  which 
frequently  falls  under  the  observation  of  the  practitioner. 
Once  comprehended,  it  explains  much  that  is  met  with  in  the 
allied  states  of  confusion  and  stupor.  We  have  already  enu- 
merated its  principal  features  in  the  preceding  chapter  on 
Classification  (see  p.  27).  These  were  illusions,  hallucinations, 
and  unsystematized  delusions.  To  these  must  be  added  ex- 
aggerated cerebral  activity  and  physical  restlessness.  Further, 
delirium  is  always  of  short  or  relatively  short  duration.  If 
asked  to  define  "dehrium,"  we  may  say  that  it  is  an  active  men- 
tal disturbance,  characterized  by  the  presence  of  illusions,  hal- 
lucinations, fragmentary,  fleeting,  unsystematized  delusions,  in- 
coherence, cerebral  excitement,  physical  restlessness,  and  by  a 
relatively  short  course. 

All  deliria  are  essentially  alike,  though  they  differ  somewhat 
in  their  details.  They  naturally  separate  themselves  into  two 
groups,  the  febrile  and  the  afebrile  forms.  The  febrile  deliria 
are  those  which  accompany  the  various  acute  infections,  the 
exanthemata,  and  the  various  acute  visceral  diseases,  such  as 
pneumonia.  The  afebrile  deliria  are  those  which  are  met  ^ith 
as  sequelae  of  various  infectious  diseases,  as  a  result  of  various 
intoxications,  and  after  trauma  or  shock.  The  afebrile  deliria 
may  have  their  onset  during  the  period  of  convalescence — the 

34 


GROUP    I — DELIRIUM,    CONFUSION,    STUPOR  35 

postfebrile  period — of  one  of  the  exanthemata,  for  example, 
typhoid  fever.  Again,  they  may  make  their  appearance  in 
cases  of  poisoning;  for  instance,  from  alcohol  or  lead. 

Under  the  head  of  the  febrile  deliria,  we  must  include  a  de- 
lirium that  has  been  described  as  a  special  form,  and  is  variously 
known  as  delirium  grave,  acute  delirious  mania,  acute  dehrium, 
typhomania,  and  Bell's  delirium.  It  appears  to  be  a  special 
clinical  entity,  and  may  with  propriety  be  spoken  of  as  ''specific 
febrile  dehrium."  To  its  consideration  we  will  presently 
return. 

The  classification  which  a  consideration  of  the  deliria  sug- 
gests is,  therefore,  the  following: 
a,  Febrile  Dehrium. 

1,  Sunple  Febrile  Dehrium. 

2,  Specific  Febrile  Dehrium. 
6,  Afebrile  Dehrium. 

SIMPLE    FEBRILE    DELIRIUM 

Etiology. — Simple  febrile  delirium  is  always  accompanied — 
in  addition  to  the  elevation  of  temperature — by  physical  signs, 
such  as  an  eruption  or  other  evidences  of  the  exanthemata,  by 
visceral  changes,  such  as  are  found  in  pneumonia  or  by  other 
indications  of  infection.  It  is  accordingly  met  with  in  typhoid 
fever,  scarlet  fever,  measles,  small-pox,  erysipelas,  influenza, 
pneumonia,  acute  articular  rheumatism,  tuberculosis,  septi- 
cemia, pyemia,  and  various  inflammations,  local  and  visceral. 
It  is  probable  that  in  these  affections  the  delirium  is  directly 
due  to  the  action  of  toxins  upon  the  cortical  neurones.  It  is  well 
known  that  poisons  introduced  from  without  may  produce  delir- 
ium, and  it  is  a  rational  hypothesis  to  ascribe  like  properties  to 
the  poisons  resulting  from  infection.  The  elevation  of  tempera- 
ture and  the  circulatory  and  respiratory  disturbances  accompa- 


36  MENTAL   DISEASES 

nying  the  infections  may  also  play  a  role  as  causal  factors,  though 
this  role  must  be  subsidiary  in  character;  it  is  well  known  that 
active  delirium  may  exist  without  fever  and  also  without  cir- 
culatory and  respiratory  disorders  of  moment.  It  is,  of  course, 
a  matter  of  common  experience  that  the  intensity  of  a  febrile 
delirium  varies  largely  with  the  intensity  of  the  fever,  being 
greater  when  the  temperature  is  highest,  and  becoming  milder 
when  the  temperature  falls;  but  this  is  probably  because  the 
higher  temperatures  are  consonant  with  higher  activities  of  the 
infectious  processes.  The  toxins  probably  act  first  upon  the 
finer  collaterals  and  dendrites,  and  later  perhaps  upon  the  cell 
bodies,  exciting,  inhibiting,  and  otherwise  perverting  the  func- 
tions of  these  various  structures. 

To  this  explanation  must  be  added  another  factor.  It  is  well 
known  that  the  occurrence  of  delirium  varies  greatly  in  differ- 
ent individuals.  Severe  infection  and  high  temperature  are 
repeatedly  encountered  without  delirium  of  moment,  while 
mild  febrile  attacks  are  occasionally  accompanied  by  delirium 
disproportionate  in  intensity  and  degree.  In  other  words, 
certain  patients  become  delirious  under  slight  provocation, 
and  there  must  be  in  them  a  feebleness  of  resistance,  a  prone- 
ness  to  mental  disturbance  not  observed  in  normal  persons. 
This  feebleness  of  resistance  is  most  frequently  associated  with 
a  neuropathic  family  history,  sometimes  with  a  personal  his- 
tory of  frequent  illnesses  with  delayed  convalescence,  or  with 
other  factors  indicating  weakness,  either  hereditary  or  ac- 
quired. Any  causes  that  weaken  the  stock,  such  as  tuber- 
culosis and  alcoholism  in  the  ancestrj^,  or  such  as  lessen  the 
individual  powers  of  resistance,  especially  the  abuse  of  poi- 
sons, notably  alcohol,  act  as  predisposing  factors.  The  reader 
must  not,  however,  infer  from  these  statements  that  the  oc- 
currence of  febrile  delirium   is   indicative   of  a  neuropathy; 


GROUP    I — DELIRIUM,    CONFUSION,    STUPOR  37 

indeed,  neuropathic  factors  are  found  in  only  a  percentage  of 
cases.  Persons  otherwise  entirely  healthy  may,  it  is  unneces- 
sary to  add,  become  dehrious  under  the  influence  of  febrile 
infections,  and  it  is  only  in  cases  in  which  an  unduly  severe 
or  intense  dehrium  attends  a  mild  infection  that  neuropathic 
factors  are  indicated. 

Symptoms  and  Course. — The  symptoms  of  the  febrile  deliria 
are,  of  course,  the  same  as  those  of  delirium  in  general.  Indi- 
vidual attacks  differ  greatly  in  degree,  due  partly  to  the  char- 
acter and  intensity  of  the  infection  and  partly  to  pecuHarities  of 
the  individual.  At  times,  the  attack  is  so  slight  that  the  patient 
appears  merely  to  be  wandering  or  half-dreaming,  and  can  be 
readily  recalled  to  himself.  Most  frequently  it  is  more  marked, 
and  at  times  it  may  be  extreme,  the  patient  becoming  noisy, 
violent,  and  even  at  times  destructive.  The  onset  may  be 
preceded  by  restlessness;  sleep  is  disturbed;  the  patient  is  dull; 
he  does  not  comprehend  easily,  nor  can  his  attention  be  readily 
held.  Very  soon  excitement  makes  its  appearance  and  may 
increase,  usually  with  the  rise  of  the  temperature  and  the  devel- 
opment of  the  other  symptoms  of  the  infection.  Illusions  make 
their  appearance.  The  patient  mistakes  the  objects  in  his  room, 
the  figures  upon  the  wall-paper,  the  persons  about  him.  Instead 
of  the  furniture,  animals,  phantastic  forms,  and  figures  are  seen. 
The  nurse,  the  mother,  or  other  relatives,  as  the  case  may  be,  be- 
come strangers  or  strange  beings.  Sounds  are  equally  misinter- 
preted; the  voices  of  friends,  foot-falls,  the  opening  and  shutting 
of  doors,  noises  in  the  street,  all  give  rise  to  illusions,  as  is  more 
or  less  evidenced  by  the  patient's  manner  and  the  phrases 
that  escape  him.  Tactile  illusions,  illusions  of  taste  and  smell, 
appear  also  to  be  present;  the  patient  misunderstands  the  at- 
tempts at  handling  him,  and  fails  to  recognize  the  drink  or 
food  that  is  offered.     At  first  he  can  be  recalled  to  himself, 


38  MENTAL    DISEASES 

and  be  made  to  realize  that  he  is  ill  and  to  understand  what  is 
being  done  for  him;  he  may  still  comply  with  requests  and  di- 
rections. Soon,  however,  the  illusions  become  more  pro- 
nounced, and  hallucinations  and  delusive  ideas  comphcate  the 
picture.  The  patient  can  no  longer  be  brought  to  a  reahzation 
of  his  surroundmgs  and  reacts  entirely  to  his  perverted  im- 
pressions and  spontaneous  sensations.  The  hallucinations 
rapidly  become  numerous  and  diversified;  soon  they  play  the 
leading  role,  and  the  delusions  which  the  patient  manifests  are 
correspondingly  varied,  changeable,  and  fleeting.  Quite  com- 
monh'  the  delusions  are  frightening,  painful,  distressing. 
Houses  are  on  fire,  people  are  being  killed,  children  are  being 
tortured,  battles  are  being  fought,  the  patient  is  compelled 
to  fight  for  his  life;  dismembered  bodies  and  other  frightful 
visions  terrify  him.  Every  now  and  then  a  lull  is  observed 
in  the  violence  of  the  sjTnptoms,  or  the  patient,  instead  of 
being  frightened,  betrays  by  smiles  and  gestures,  by  expressions 
of  pleasure  or  rapture,  that  he  is  in  a  stage  of  exaltation,  a 
stage  which  proves,  however,  to  be  very  short-lived,  for  soon 
the  painful  and  terrifying  hallucinations  and  delusions  again 
assert  themselves. 

The  intensity  of  the  delirium  depends  both  upon  the  severity 
of  the  infection  and  upon  the  feebleness  or  strength  of  resistance 
of  the  patient,  and  in  estimating  the  significance  of  dehrium  in 
a  given  case  both  these  factors  must  be  borne  in  mind.  Further, 
it  is  a  more  decided  complication  in  some  affections  than  in 
others;  thus,  it  is  commonly  more  pronounced  in  typhoid  fever 
than  in  any  other  of  the  exanthemata. 

As  already  indicated,  the  delirium  becomes  more  marked 
with  the  rise  of  the  temperature  and  the  advance  of  the  infec- 
tion; soon,  however,  it  ceases  to  keep  pace  with  the  latter,  the 
excitement  lessens,  the  violence  of  the  symptoms  abates,  the 


GROUP    I — DELIRIUM,    CONFUSION,    STUPOR  39 

patient  becomes  clear  or  relatively  so ;  or  a  muttering  delirium, 
the  restlessness  of  which  expresses  itself  by  a  tugging  or  picking 
at  the  bed-clothes,  becomes  established.  In  severe  cases,  the 
patient  may  pass  into  a  condition  of  coma  or  stupor.  Usually 
all  traces  of  delirium  disappear  when  the  infection  has  spent 
its  force,  the  patient's  mind  becoming  entirely  normal.  Rarely, 
however,  some  degree  of  mental  weakness  persists  for  a  time; 
sometimes  for  months  or  even  for  years. 

Diagnosis.— The  diagnosis  of  a  febrile  dehrium  is,  of  course, 
readily  made;  indeed,  more  readily  sometimes  than  the  diag- 
nosis of  the  disease  of  which  it  is  an  accompaniment. 

Prognosis. — A  febrile  delirium  is  quite  commonly  a  negligible 
factor.  Only  when  it  is  unusually  severe  does  it  acquire  signifi- 
cance. It  may  then  indicate  a  very  grave  infection  or,  what 
is  equally  ominous,  feebleness  of  resistance  on  the  part  of  the 
patient.  As  far  as  the  mind  of  the  patient  is  concerned,  the 
prognosis  is  quite  favorable,  save  in  a  very  small  percentage  of 
cases,  in  which,  as  already  stated,  mental  weakness  may  for  a 
time  persist. 

SPECIFIC    FEBRILE    DELIRrUM 

The  affection,  which  I  have  myself  termed  ''specific  febrile 
delirium,"  is  knowm  by  a  number  of  synonyms,  all,  I  believe, 
more  or  less  open  to  objection;  thus,  it  is  spoken  of  as  "acute 
dehrium"  a  term  which  is  not  definitive,  because  aU  dehria  are 
acute;  secondly,  it  is  spoken  of  as  "acute  dehrious  mania," 
although  it  is  in  no  sense  a  mania;  the  same  objection  ap- 
phes  to  the  older  term  "typhomania."  The  names  "Bell's 
delirium"  and  "delirium  grave"  are  somewhat  less  objection- 
able, though  thej^  both  lack  a  distinctive  signification.  The 
term  "specific  febrile  delirium"  seems  to  me  to  be  especially 
apphcable.  The  affection  is  distinguished  from  ordinarj^ 
febrile  dehrium  by  the  fact  that  there  are  never  present  any 


40  MENTAL   DISEASES 

physical  signs,  merely  a  high  temperature,  together  with 
an  intense  delirium.  Specific  febrile  delirium  may  be  defined 
as  a  delirium,  very  active,  characterized  by  a  febrile  state, 
the  rise  of  temperature  being  generally  quite  high,  while 
there  are  not  present  any  surface  lesions  such  as  are  found 
in  the  exanthemata,  nor  any  sign  of  visceral  involvement, 
such  as  pneumonia  or  meningitis. 

Etiology. — It  is  a  rare  disease,  and  but  little  is  known  re- 
garding its  etiolog>^  It  appears  to  be  an  affection  of  adult  life, 
occurring  most  frequently  betw^een  twenty-five  and  forty  years 
of  age.  It  would  appear  also  from  the  statements  of  several 
writers  that  it  occurs  more  frequently  in  women  than  in  men, 
though  this  hardly  accords  wdth  the  experience  of  the  writer. 
It  is  said,  also,  that  neuropathic  features  are  frequently  pre- 
sented by  both  the  family  and  the  personal  histories  of  the 
patient.  Other  equally  vague  and  unsatisfactory  statements 
are  made  in  regard  to  the  previous  existence  of  exhausting  and 
debilitating  affections,  grief,  depressing  emotions,  trauma, 
fatigue,  excesses,  and  bad  hygiene.  The  very  number  and  char- 
acter of  these  factors  rob  them  of  any  specific  value;  they 
could  only  act  by  diminishing  the  resistance  of  the  nervous 
system  to  toxic  or  infectious  processes,  and  could  not  of  them- 
selves play  any  r61e  other  than  that  of  secondarj^  or  predisposing 
causes. 

Symptoms  and  Course. — The  onset  of  the  disease  is  usually 
very  rapid;  often  sudden.  Sometimes,  however,  a  prodromal 
period  has  been  noted,  varying  in  duration  from  several  hours 
to  a  day  or  more.  During  this  time  there  may  be  present  in- 
somnia, irritability,  intolerance  of  light  and  soimds,  headache, 
tinnitus,  anorexia,  lassitude,  weakness,  and  perhaps  uncer- 
tainty of  gait.  Narrowness  of  the  pupils  has  also  been  noted. 
Soon,  usually  within  twenty-four  hours,  a  delirium  makes  its 


GROUP    I — DELIRIUM,    CONFUSION,    STUPOR  41 

appearance,  which  rapidly  assumes  a  great  intensity.  It  is 
furious  in  character,  the  patient  raves,  shouts,  sings;  his  fea- 
tures express  in  rapid  sequence  fright,  anger,  terror,  anguish, 
ecstacy.  He  struggles,  tries  to  escape  or  to  hide,  he  weeps, 
shrieks,  or  may,  for  brief  intervals,  laugh  or  smile.  From  his 
lips  issue  fragments  of  sentences,  broken  phrases,  half-articu- 
lated words.  He  is  entirely  obtunded  to  his  surroundings,  he 
cannot,  as  in  deliria  of  less  violent  form,  be  brought  in  any  degree 
to  a  realization  of  his  surroundings.  Indeed,  even  illusions 
are  not  formed,  and  the  patient  appears  to  be  entirely  at  the 
mercy  of  his  hallucinations.  The  latter  are,  in  the  main,  painful 
and  terrifying,  as  are  the  disordered  ideas  to  which  they  give 
rise,  and,  in  this  respect,  the  symptoms  resemble  those  of 
ordinary  febrile  deHrium,  save  that  they  are  magnified  and  ac- 
centuated. Paroxysms  of  terror  associated  with  staring  eyes, 
shrieks,  and  mad  struggling  can  only  depend  upon  frightful 
hallucinations;  and  the  phrases  the  patient  utters,  often  under- 
stood mth  difficulty,  are  of  murder,  fire,  blood,  and  tortures. 
The  ideas  reveal  no  sequence  other  than  that  of  a  torrent  of 
disordered  and  fragmentary  delusions,  painful  in  the  extreme. 
Certain  ideas  may  recur,  or  certain  groups  of  ideas,  such  as  of 
fire  and  of  being  burnt  alive,  of  torture  or  poisoning,  may  pre- 
dominate, but  no  coherence  or  systematization  obtains. 

The  patient's  restlessness  is  extreme;  in  the  intervals  of  his 
struggles  he  is  in  a  continual  state  of  agitation,  and  constantly 
moving  unless  restrained.  He  is  picking  or  pulling  with  his 
hands,  tearing  at  his  clothes,  grasping  at  the  air,  pushing 
away  or  warding  off  imaginary  dangers.  He  may  spring  from 
his  bed,  throw  himself  against  the  walls,  furniture,  or  attend- 
ants. As  might  be  expected,  food  and  drink  can  rarely  be  ad- 
ministered; the  food  may  be  retained  in  the  mouth  for  a  mo- 
ment, only  to  be  suddenly  ejected;  at  times  a  mouthful  may 


42  MENTAL    DISEASES 

be  gulped;  more  frequently  it  is  impossible  to  get  the  patient 
to  take  anything.  Food  is  not  recognized,  and  the  patient, 
already  having  ideas  of  poisoning  or  torture,  struggles  against 
it.  Even  when  introduced  forcibly  by  the  stomach-tube,  it 
may  not  be  retained,  due  alike  to  the  struggling  and  to  the 
anorexia  which  is  undoubtedly  present. 

The  temperature  of  the  patient  is  always  elevated;  indeed, 
high  fever  is  a  characteristic  feature  of  the  disease.  The 
temperature  rapidly  rises  to  102°  or  103°  F.,  and  ranges  for  a 
time  in  the  neighborhood  of  104°  F.  It  often  attains  105° 
and  even  106°  F.,  and  persists,  as  a  rule,  until  shortly  before 
death,  when  it  may  rapidly  fall;  at  times,  however,  this  defer- 
vescence does  not  take  place,  the  high  temperature  persisting 
until  death  ensues. 

The  pulse  is  rapid  and  of  high  tension;  it  soon  becomes  small 
and  irregular.  It  may  vary  from  120  to  140  per  minute;  very 
rarely  is  it  slow.  The  respirations  are  also  increased  in  fre- 
quency and  are  sometimes  irregular;  toward  the  termination  of 
the  attack  they  may  assume  a  Cheyne-Stokes  character.  The 
breath  is  foul,  the  tongue  becomes  heavily  coated  and  the  teeth 
covered  with  sordes.  The  bowels  at  first  are  obstinately  con- 
stipated, but  later,  as  exhaustion  supervenes,  an  offensive, 
colliquative  diarrhea  sets  in.  The  urine  is  scanty  and  high 
colored.  The  chlorids  are  diminished,  albumin  may  be  present, 
and  occasionally  hyaline  casts  are  found.  The  saUva  appears  to 
be  increased;  the  patient  maj'  drool  freely.  Sweating  also  may 
be  marked,  especially  at  first,  though  later  the  skin  becomes 
dry. 

The  affection  pursues  a  rapid  course.  If  death  does  not  soon 
supervene — it  may  take  place  as  early  as  the  third  day — col- 
lapse makes  its  appearance.  The  delirium  becomes  low  and 
muttering,  and  finally  gives  way  to  stupor.    The  temperature 


GROUP    I — DELIRIUM,    CONFUSION,    STUPOR  43 

becomes  subnormal,  the  features  pale  and  shrunken,  and 
death  ensues  from  exhaustion.  The  entire  duration  of  the 
attack  may  be  six  or  seven  days;  rarely  does  it  extend  over  a 
longer  period,  though  cases  of  two  and  three  weeks  have  been 
recorded.  Convulsive  seizures,  general  or  local  in  character, 
occasionally  complicate  the  picture. 

In  the  very  few  cases  that  recover,  the  convalescence  is 
tedious  and  difficult.  As  in  other  exhausting  affections — e.  g., 
typhoid  fever — the  hair  may  fall  out;  at  times  the  nails  are 
lost;  general  emaciation  is  extreme;  there  is  also  wasting  of 
muscles;   even  spontaneous  gangrene  may  supervene. 

Pathology. — A  postmortem  examination  may  reveal  nothing 
whatever,  the  brain,  its  membranes  and  vessels,  being  entirely 
normal  to  the  naked  eye.  Usually,  however,  the  macroscopic 
examination  reveals  a  marked  hyperemia  and  injection  of  the 
membranes  and  cortex.  The  subdural  space  and  the  meshes 
of  the  pia-arachnoid  may  contain  an  excess  of  cerebrospinal 
fluid;  the  vessels  of  the  pia  may  be  full  of  blood,  and  here  and 
there  marked  engorgement  or  even  slight  hemorrhagic  exuda- 
tions may  be  noted.  The  pia  may  be  stripped  off  the  convolu- 
tions with  unusual  ease,  and  section  of  the  brain  substance  may 
reveal  a  finely  punctate  appearance;  indeed,  it  may  present  a 
distinct  tinge  of  red.  At  other  times  the  pia  may  be  slightly 
opalescent,  or  there  may  be  evidences  of  infiltration  along  its 
vessels,  and,  instead  of  being  abnormally  loose,  it  may  here 
and  there  be  adherent. 

A  microscopic  examination  may  reveal  a  marked  chromatoly- 
sis  of  the  cells  of  the  cortex,  together  with  shrinkage,  deformity, 
displacement  of  the  nucleus,  enlargement  of  the  nucleus, 
together  with  varicosities  of  the  cell  processes.  Similar  changes 
have  been  noted  in  the  cells  of  the  cerebellum,  the  medulla, 
and  cord.     The  neurogha  may  reveal  evidences  of  proUfera- 


44  MENTAL    DISEASES 

tion,  especially  about  the  vessels;  its  nuclei  may  be  increased 
and  its  network  more  pronounced. 

The  changes  observed  seem  to  indicate  the  action  of  some 
poison,  most  probably  the  toxin  of  some  infection.  However, 
the  evidence  at  hand  is  as  yet  extremely  meager  and  unsatis- 
factory. Bianchi  and  Piccinino  have  described  a  bacillus 
found  in  the  blood  of  delirium  grave  which  is  not  found  in  other 
deliria,  and  which  they  believe  to  be  specific.  However, 
other  observers  have  noted  the  presence  in  the  blood  of 
staphylococci,  streptococci,  and  diplococci,  to  which  obviously 
no  specificity  could  be  ascribed.  Again,  others  still,  such  as 
Cabitto,  have  failed  in  undoubted  delirium  grave  to  find  any 
microbic  infection  whatever. 

It  is  impossible,  of  course,  in  the  present  state  of  our  knowl- 
edge to  form  a  definite  opinion,  or  even  to  determine  whether 
deUrium  grave  is  a  specific  infectious  disease.  Indeed,  it  is 
not  impossible  that  it  is  a  syndrome  which  may  be  the  outcome 
of  diverse  infective  agents.  However  this  may  be,  it  must  be 
admitted  that  delirium  grave  is  a  clinical  entity;  that  it  pre- 
sents special  features  as  regards  its  evolution,  its  symptoms, 
its  course,  and  its  termination,  and  as  such  it  demands  special 
study  and  consideration. 

Diagnosis. — The  absence  of  the  physical  signs  of  the  exanthe- 
mata and  of  the  visceral  diseases  of  infectious  origin,  together 
with  the  presence  of  a  delirium  of  rapid  evolution  and  great 
intensity,  accompanied  by  high  temperature,  should  suggest 
at  once  the  existence  of  specific  febrile  delirium.  In  other 
affections,  the  history  of  a  period  of  invasion  and  the  signs 
present  at  the  time  of  the  evolution  of  the  delirium  leave,  as  a 
rule,  no  doubt  of  the  existence  of  one  of  the  eruptive  fevers, 
erysipelas,  pneumonia,  meningitis,  articular  rheumatism,  or  of 
pelvic,  abdominal,  or  other  local  lesions.  The  cUnical  picture 
is  always  very  different;  thus,  in  a  meningitis,  the  dehrium  is 


GROUP    I — DELIRIUM,    CONFUSION,    STUPOR  45 

much  less  pronounced,  restlessness  is  but  little  marked,  while 
there  are  present  intense  headache,  vomiting,  convulsions,  local 
or  general,  palsies,  ocular  involvement,  and  the  other  signs 
unnecessary  to  enumerate  here.  Rarely  one  of  the  exanthemata 
is  ushered  in  by  a  high  temperature  and  an  active  deUrium,  but 
the  subsequent  course  early  solves  the  problem.  Again,  every 
now  and  then  an  active  delirium  occurs  as  an  episode  in  paresis 
or,  more  rarely,  as  an  episode  in  a  case  of  mania.  In  such  in- 
stance, of  course,  the  presence  of  the  physical  signs  of  paresis, 
and,  in  mania,  the  history  of  the  case  and  absence  of  high  tem- 
perature, suffice  to  make  the  differential  diagnosis.  Similarly, 
a  case  of  alcohoHc  delirium  (dehrium  tremens)  might,  because 
of  its  intensity,  suggest  specific  febrile  dehrium,  especially  when 
accompanied  by  fever.  Here,  besides  the  alcohoHc  history 
and  the  evident  coarse  signs  of  alcohoHsm,  we  have  the  tremor 
of  the  lips,  the  tongue  and  limbs,  and,  especially,  the  great  pre- 
dominance of  visual  hallucinations.  In  practice  no  difficulty 
is  experienced  in  differentiating  the  various  toxic  deliria  from 
the  specific  febrile  form.  The  temperature  in  the  former  is 
rarely  pronounced,  the  delirium  is  much  less  active,  and  the 
clinical  history  and  symptoms  leave  little  room  for  doubt. 

Prognosis. — As  has  already  been  pointed  out  in  the  study 
of  the  symptoms,  the  prognosis  of  specific  febrile  delirium  is 
grave  in  the  great  majority  of  cases.  Death,  as  a  rule,  super- 
venes before  the  fourth  day,  though,  as  already  stated,  fife 
may  be  prolonged  to  the  fifth,  sixth,  seventh  day,  or,  in  rare 
instances,  for  longer  periods.     A  few  cases  only  survive. 

AFEBRILE    DELIRIUM 

(Delirium  of  Exhaustion,  Postfebrile  Delirium) 

Etiology. — Every  now  and  then  it  happens  during  the  course 

of  an  infectious  disease,  such  as  t;>TDhoid  fever,  especially  near 

its  termination,  that  there  is  a  sudden  defervescence  of  tempera- 


46  MENTAL    DISEASES 

ture,  and  that  this  is  either  accompanied  or  followed  by  an 
attack  of  delirium.  Again,  it  may  be  that  the  infectious  dis- 
ease from  which  the  patient  suffers  has  pursued  and  completed 
a  normal  course,  and  that  the  patient  has  entered  the  stage  of 
convalescence,  when  the  latter  is  interrrupted  by  an  attack  of 
delirium.  As  might  be  expected,  afebrile  delirium  may  occur 
in  widely  separate  affections.  Thus,  it  may  occur  during  or  as 
a  sequel  in  the  various  exanthemata,  in  typhoid  fever,  in 
pneumonia,  in  influenza,  and  in  various  other  conditions  in 
which  sudden  exhaustion  may  supervene;  for  example,  in 
labor,  in  the  puerperium,  sudden  hemorrhage,  surgical  shock, 
great  emotional  shock,  and  fright.  There  is  present  in  some 
cases  in  which  such  a  delirimn  occurs  an  undoubted  predis- 
position to  mental  disturbance — a  hereditary  neuropathic 
make-up — but  this  is  probably  true  of  less  than  half  the  cases. 
Symptoms  and  Course. — The  onset  is  usually  sudden, 
though  at  times  prodromal  symptoms  may  be  noted.  Thus, 
for  a  day  or  two  insomnia  and  an  ominous  restlessness  may  make 
their  appearance.  Consciousness  becomes  much  obscured; 
the  patient  loses  the  proper  appreciation  of  his  surroundings; 
he  becomes  illusional,  everything  seems  strange  and  changed; 
soon,  also,  he  becomes  hallucinatorj'^  to  an  extreme  degree.  The 
chairs  and  other  objects  in  the  room  are  mistaken  for  strange 
shapes,  persons,  or  animals.  The  individuals  about  his  bed 
are  no  longer  properly  recognized.  The  pictures  upon  the  walls, 
the  curtains  upon  the  windows,  the  rugs  upon  the  floor,  all 
become  animated  objects.  As  in  other  forms  of  delirium,  the 
hallucinations  which  manifest  themselves  are  varied  and  nu- 
merous, and,  if  the  attack  be  severe,  may  become  very  pro- 
nounced. Voices  call  to  the  patient,  strange  figures  beckon  to 
or  terrify  him.  Delusions,  fragmentary,  painful,  and  frightful — 
delusions  of  torture,  fire,  poisoning,  assassination — crowd  in 
hurried  frenzy  through  his  mind.     His  struggles  are  those  of 


GROUP    I — DELIRIUM,    CONFUSION,    STUPOR  47 

fear,  and  though  at  times  we  note  a  smile,  a  laugh,  or  a  grimace, 
indicating  a  pleasurable  or  expansive  state,  such  a  state  is 
always  of  brief  duration,  soon  giving  way  again  to  signs  of  fear 
or  terror. 

The  speech  of  the  patient,  as  can  readily  be  surmised,  is 
for  the  most  part  fragmentary  and  confused,  and  his  delusive 
ideas  are  difficult  if  not  impossible  to  follow.  The  patient 
cries  out  or  utters  merely  parts  of  sentences  or  phrases,  or  his 
speech  may  be  entirely  incoherent  or  consist  of  senseless  repeti- 
tions or  alhterations.  He  may  talk  loudly,  excitedly,  or  he 
may  whisper,  gesticulate,  or  make  grimaces.  It  is  generally 
impossible  to  obtain  a  rational  answer  to  a  question,  though 
sometimes,  during  a  momentary  lull,  the  patient  may  comply 
with  a  given  direction.  Sleep,  unless  induced  bj^  artificial 
means,  is  abohshed.  Food  and  medicine  are  administered 
\\dth  great  difficulty.  As  the  delirium  progresses,  the  mind 
becomes  more  and  more  obtunded,  the  movements  become  pur- 
poseless, the  struggUng  senseless  and  automatic,  the  patient 
turning  about  the  bed,  pulling  and  pushing,  or  making  aimless 
gestures.  The  physical  condition  is  indicative  of  great  pros- 
tration. The  surface  of  the  body  is  cold,  pale,  and  moist.  The 
pulse  is  small,  sometimes  slow,  more  frequently  rapid.  Mus- 
cular weakness  is  pronounced.  Incontinence,  also,  is  usually 
present. 

Afebrile  delirium  is  an  affection  of  short  duration.  It  may 
last  only  a  few  hours ;  it  never  extends  over  more  than  a  few 
days.  Recovery  is  manifested  by  the  gradual  return  of  the 
power  to  recognize  the  surroundings.  The  patient  begins  to 
comply  with  the  directions  of  the  nurse,  takes  his  food,  and, 
above  all,  begins  to  sleep.  Not  infrequently  the  return  to 
lucidity  is  quite  rapid,  and,  as  a  rule,  the  recovery  is  unin- 
terrupted; but  at  times  it  is  broken  in  upon  by  recurrences  of 


48  MENTAL    DISEASES 

delirium  or  confusion,  usually  transient  in  character.  Along 
with  the  other  signs  of  improvement,  we  observe  a  gain  in  the 
physical  condition  and  a  disappearance  of  the  restlessness. 
During  the  convalescence,  we  may  note  that  the  patient  is 
emotional,  irritable,  or  excitable.  All  of  these  symptoms, 
though  they  may  persist  for  several  weeks,  finally  disappear. 
The  patient  remembers  very  little  of  the  attack;  indeed, 
usually  nothing  of  the  height  of  the  attack.  Such  matters  as 
he  does  remember  are  usually  remembered  very  imperfectly. 

Pathology. — Undoubtedly,  two  factors  play  the  leading  role 
in  the  production  of  the  afebrile  deUria:  first,  exhaustion,  and 
second,  toxemia.  The  exhaustion  lessens  the  resistance  of  the 
nerv^e-centers  to  the  toxins  of  the  infection — toxins  which  are 
probably  being  imperfectly  eliminated  or  otherwise  slowly 
disposed  of,  and  which  are  cumulative  in  their  action.  Specific 
changes  in  the  nerve-centers,  attributable  to  the  delirium,  have 
not  been  described;  cases  very  infrequently  come  to  autops3\  It 
is  unlikely,  because  of  the  prompt  and  speedy  recovery  ensuing 
in  most  cases,  that  changes  of  moment  take  place  in  the  nerve 
tissue. 

Diagnosis. — The  features  upon  which  the  diagnosis  is  to  be 
based  are  briefly  as  follows :  First,  the  history  of  an  antecedent 
febrile  disease,  of  a  shock,  of  sudden  hemorrhage,  trauma,  or 
other  acutely  debihtating  cause;  second,  the  rapid  appearance 
of  excessive  mental  confusion  with  marked  excitement  and 
restlessness,  abnormal  rapidity  in  the  flow  of  ideas,  together 
with  marked  obtusion  and  the  obvious  presence  of  illusions, 
hallucinations,  and  unsystematized  delusions;  third,  signs  of 
a  sudden  and  acute  physical  prostration;  fourth,  the  absence 
of  fever. 

Afebrile  delirium  must  be  differentiated  from  epileptic  de- 
lirium, alcoholic  delirium,  the  intercurrent  deUrium  of  pare- 
sis, and  from  confusional  insanity.      Epileptic  deUrium  is  to 


GROUP    I — DELIRIUM,    CONFUSION,    STUPOR  49 

be  differentiated  by  the  history  of  epileptic  seizures,  usually 
obtainable,  by  the  absence  of  a  history  of  antecedent  febrile  or 
other  acutely  debilitating  cause,  by  the  absence  of  the  physical 
signs  of  collapse,  by  the  complete  loss  of  consciousness,  and  by 
such  phenomena  as  epileptic  automatism.  Delirium  tremens 
is  to  be  differentiated  by  the  history  of  alcoholism,  by  the 
presence  of  the  physical  signs  of  alcohohsm,  by  the  absence  of 
an  antecedent  history  of  febrile  or  other  exhausting  disease, 
and  especially  by  the  predominance  of  visual  hallucinations. 
The  intercurrent  deUrium  of  paresis  is  to  be  distinguished  by  the 
histoiy  of  the  case  and  the  physical  signs  of  paresis.  From 
confusional  insanity,  afebrile  dehrium  is  to  be  separated  by  its 
stormy  development,  by  the  greater  intensity  and  activity  of 
its  symptoms,  both  mental  and  physical,  and  by  its  rapid  and 
short  course. 

Prognosis. — Other  things  equal,  the  prognosis  of  afebrile 
delirium  is  good.  The  large  majority  of  cases  recover.  The 
prognosis  is  grave  only  in  cases  in  which  the  physical  condition 
is  precarious.  Again,  rarely  the  delirium  does  not  subside 
completely,  and  the  patient  passes  into  a  condition  of  more  or 
less  persistent  confusion  lasting  for  a  variable  period,  some- 
times for  many  weeks.  Still  more  rarely  the  delirium  eventu- 
ates in  a  stupor  which  likewise  proves  of  long  duration.  In 
either  case,  however,  the  ultimate  outcome  is  one  of  recovery 
in  the  majority  of  cases. 

CONFUSION 
Confusion,  also  spoken  of  as  confusional  insanity,  as  amentia 
(Meynert),  and  as  Verwiirtheit,  presents  itself  under  various  clin- 
ical forms,  all,  however,  closely  related.  In  its  more  active  and 
pronounced  forms,  it  resembles  and,  indeed,  approximates  de- 
lirium.   On  the  other  hand,  it  may  be  so  slightly  pronounced, 

4 


50  MENTAL    DISEASES 

the  symptoms  so  mild  in  degree,  that  only  a  state  of  mild  mental 
confusion  may  be  present;  indeed,  it  may  be  so  light  as  to  be 
represented  by  merely  a  slightly  dazed  state  of  mind.  The  less 
active  form  of  confusion  may  properly  be  termed  passive,  and 
we  at  once  add  clearness  to  our  clinical  conceptions  by  recog- 
nizing at  the  outset  the  existence  of  these  widely  differing  forms; 
namely,  active  confusion  and  passive  confusion.  Again,  in  the 
active  form — perhaps  as  a  result  of  increasing  toxicity  and  ex- 
haustion— the  patient  may  become  very  dull  and  heavy  and 
his  confusion  very  deep,  so  as  to  suggest  stupor.  In  other  words, 
just  as  confusion  when  attended  by  marked  activity  and  ex- 
citement may  approximate  delirium,  so  may  it,  on  the  other 
hand,  approximate  stupor. 

However  widely  the  forms  of  confusion  differ  from  each 
other,  the  underlying  features  are  always  the  same.  There 
is  always  present  some  degree  of  mental  obtusion;  in  conse- 
quence, illusions  as  to  objects,  surroundings,  and  persons 
may  be  observed.  Hallucinations,  if  present,  are  markedly 
so  only  in  the  more  active  forms.  Delusions  unsystema- 
tized in  character,  or  in  the  passive  forms,  perhaps  feebly  sys- 
tematized, are  present  in  almost  all  cases;  in  the  forms  which 
approximate  stupor  they  may  be  absent. 

Etiology. — In  the  etiology  of  confusion,  we  have  to  deal,  as 
in  delirium,  with  the  two  factors  of  exhaustion  and  toxemia. 
In  the  more  active  form,  the  confusion  stands  in  undoubted 
relation  to  the  infections,  and  it  not  infrequently  occurs  during 
the  convalescent  or  postfebrile  period  of  the  exanthemata, 
just  as  does  afebrile  delirium.  Thus,  it  may  follow  typhoid 
fever,  variola,  erysipelas,  pneumonia,  influenza,  puerperal  in- 
fections, acute  articular  rheumatism,  and  allied  conditions. 

At  other  times,  and  especially  in  its  less  active  forms,  confu- 


GROUP    I — DELIRIUM,    CONFUSION,    STUPOR  51 

sion  may  stand  in  close  relation  to  various  auto-intoxications. 
Unfortunately,  our  knowledge  of  this  subject  does  not  permit 
of  accurate  statements.  It  would  appear,  however,  that  the 
confusion  now  and  then  met  with  in  metabolic  affections,  such 
as  gout  and  rheumatism,  bears  a  direct  relation  to  the  toxemia 
of  these  disorders.  Equally  probable  is  it  that  the  confusion 
occasionally  observed  in  diseases  of  the  viscera,  for  example,  of 
the  liver  and  kidneys,  is  due  to  toxins  formed  in  these  organs; 
at  other  times,  to  a  failure  of  elimination  of  substances  normally 
present  in  the  body.  There  is  also  reason  to  believe  that, 
under  given  conditions,  confusion  may  be  the  result  of  a  gastro- 
intestinal intoxication,  though,  on  the  whole,  such  an  etiology 
appears  to  be  infrequent. 

Toxic  agents  introduced  from  without  may  also  play  a  role. 
Especially  is  this  the  case  with  alcohol,  the  various  narcotics, 
and  other  poisons.  Inasmuch  as  these  toxic  insanities  present 
special  clinical  features  they  are  considered  separately.  (See 
Part  II.)     Their  discussion  here  would  lead  us  too  far  afield. 

In  considering  the  etiology  of  confusion,  it  becomes  evident 
that  many  of  the  causes  indicated,  especially  the  infections  and 
the  auto-intoxications,  only  produce  confusion  in  a  small  pro- 
portion of  cases.  Taking  into  consideration  the  large  number 
of  cases  of  various  kinds  of  infection  and  intoxication  observed 
in  the  hospitals  and  in  private  practice,  the  proportion  of  cases 
of  confusion  is  relatively  small.  Evidently  other  causes  must 
be  at  work,  and  these  appear  to  be  in  some  cases  exhaustion  • 
and  in  others  a  pre-existing  neuropathy,  both  of  which  factors 
diminish  the  resistance  of  the  nervous  system  to  the  action  of 
toxic  agents.  In  about  one-half  the  cases,  as  in  delirium,  there 
is  a  clear  family  history  of  insanity.  Indeed,  it  is  not  infrequent 
to  meet  with  an  account  of  cases  presenting  similar  attacks 
or  of  cases  of  manic-depressive  or  other  psychoses  in  the  an- 


52  MENTAL    DISEASES 

cestry.  Among  causes  of  exhaustion  we  must  recognize  such 
factors  as  the  physical  depletion  attendant  upon  the  various 
acute  infectious  diseases,  mental  and  emotional  overstrain, 
physical  overexertion,  excessive  worry,  and  prolonged  lactation. 

Symptoms  and  Course. — Confusion  when  active — as  already 
pointed  out — approximates  delirium,  though  the  excitement 
is  less  marked  and  the  affection  itself  much  more  prolonged. 
However,  because  of  its  activity  it  has  received  such  designa- 
tions as  "mania  hallucinatoria"  (Mendel)  and  "hallucinatorische 
Ven\'irrtheit"  (hallucinatory  confusion,  Meynert),  names  which 
convey  the  notion  of  its  two  prominent  features — activity  of 
symptoms  and  the  presence  of  hallucinations.  It  is  to  this 
active  form  that  we  will  first  give  our  attention. 

The  onset  is  less  rapid  than  in  delirium.  The  patient  is 
sleepless  and  restless,  nervous,  very  much  afraid,  and  excited. 
He  talks  of  dying,  has  a  fear  of  some  impending  evil  or  disaster, 
becomes  forgetful,  is  unable  to  properly  collect  his  thoughts, 
complains  that  he  cannot  think,  and,  Uttle  by  little,  becomes 
heavy,  dull,  and  confused.  In  the  course  of  a  few  days  these 
symptoms  become  more  pronounced.  The  patient  begins  to 
lose  the  correct  appreciation  of  his  surroundings.  He  fails  to 
recognize  his  room,  the  bed,  and  other  objects,  as  well  as  the 
persons  about  him.  He  does  not  know  where  he  is,  and  often 
begs  to  be  taken  home.  He  understands  very  imperfectly 
what  is  said  to  him.  Sometimes  he  catches  a  word  or  phrase, 
but  usually  mistakes  its  meaning.  The  commonest  objects 
fail  to  be  recognized;  a  spoon  or  a  thermometer  may  inspire 
deadly  fear;  the  prick  of  a  hypodermic  needle  may  be  mis- 
taken for  an  onslaught  with  a  dagger.  The  consciousness  of 
the  patient  is  more  or  less  obtunded,  but  sometimes  it  is 
possible  to  attract  his  attention  for  a  brief  period  by  speak- 
ing plainly  and  repeatedly  to  him. 


GROUP    I — DELIRIUM,    CONFUSION,    STUPOR  53 

Hallucinations  also  make  their  appearance,  and  these  are 
painful  and  distressing.  The  patient  sees  frightful  objects  and 
hears  threatening  voices,  and  it  is  not  surprising  that  his  illu- 
sions and  hallucinations  should  in  turn  give  rise  to  delusions. 
These  are  unsystematized  in  character,  or  at  most  betray  only 
a  feeble  and  fragmentary  systematization.  He  is  about  to  be 
tortured  or  destroyed,  or  such  a  fate  is  in  store  for  others  whom 
he  holds  dear.  As  in  delirium,  he  may  hear  shrieks  and  curses, 
or,  more  rarely,  may  have  terrifying  visual  hallucinations. 
On  the  whole,  the  auditory  hallucinations  greatly  predominate. 
Rarely,  and  usually  for  brief  periods  of  time,  the  hallucinations 
appear  to  be  pleasurable. 

The  illusions  play  an  even  greater  role  than  the  hallucinations. 
They  make  their  appearance  early,  and,  frequently,  by  their 
prominence  obscure  the  presence  of  the  hallucinations.  Usually, 
however,  in  the  active  form  here  described,  the  hallucinations 
are  quite  evident. 

As  the  confusion  becomes  established,  consciousness  becomes 
more  obscured,  so  that  it  may  no  longer  be  possible  to  arouse 
the  attention  of  the  patient.  The  train  of  thought  is  dis- 
ordered and  confused,  while,  as  in  delirium,  there  is  usually 
some  excitement  and  hurry  of  thought.  Consciousness  is 
obscured  and  often  dreamlike.  The  prevailing  emotional  tone 
is  one  of  depression,  though  sometimes  laughter  and  singing 
and  other  evidences  of  exaltation  are  observed.  As  a  rule, 
however,  signs  of  exaltation  are  present  for  brief  periods;  very 
infrequently  do  they  form  a  feature  of  the  clinical  picture.  In 
rare  instances,  however,  they  are  so  marked  as  to  alternate  with 
periods  of  depression. 

Motor  excitement  is  usually  present,  though  it  is  much  less 
marked  than  in  delirium.  However,  the  patient  is  restless,  and 
may  even  try  to  get  out  of  bed,  to  run  about  the  room,  or  to 


54  MENTAL    DISEASES 

escape  from  his  attendants.  Occasionally,  instead  of  restless- 
ness, there  is  motor  quiet;  the  patient  may  lie  perfectly  still. 
In  some  cases,  he  may  remain  a  long  time  in  one  position,  and 
his  attitude  may  suggest  the  fixation  met  with  in  catatonia 
(see  Part  I,  Chapter  V).  However,  this  is  infrequent  in  cases 
in  which  the  confusion  is  active.  This  statement  likewise 
apphes  to  the  symptom  known  as  automatism;  the  patient 
may  preserve  for  a  time  a  given  attitude  in  which  he  happens 
to  be  placed  by  his  attendant. 

The  speech  of  the  patient  is  more  or  less  incoherent,  usually 
markedly  so,  and  the  confusion  of  his  ideas  very  evident. 
Sleep  is  much  disturbed.  The  patients  sleep  but  little  except 
as  the  result  of  medication,  bathing,  or  other  measures.  Food 
is  administered  with  difl&culty,  partly  from  loss  of  appetite, 
partly  as  a  result  of  fear  and  suspicion,  and  partly  because  of 
inability  on  the  part  of  the  patient  to  recognize  the  proffered 
nourishment  as  food.  The  nutrition  falls  and  there  is  loss  of 
weight.  The  patient  may  or  may  not  be  indifferent  to  the 
bladder  and  bowels;  if  the  confusion  is  deep,  he  may  be  in- 
continent. 

The  tendon  reflexes  may  be  exaggerated;  especially  is  this 
the  case  when  the  excitement  is  mark«l.  The  pulse  is  slow, 
the  temperature  normal  or,  now  and  then,  subnormal. 

As  a  rule,  the  symptoms  reach  their  full  development  in 
about  ten  days  or  two  weeks.  The  subsequent  course  is  always 
more  or  less  irregular,  the  confusion  being  at  times  less  and  at 
times  more  pronounced.  This  condition  persists  with  varying 
intensity  for  weeks  and  months,  until  gradually  a  return  to  the 
normal  takes  place.  Convalescence  is,  as  a  rule,  gradual. 
Little  by  httle  the  patient,  for  periods  of  time,  becomes  appre- 
ciative of  his  surroundings.  The  periods  of  lucidity  become 
more  prolonged  until  convalescence  is  fully  established. 


GROUP    I — DELIRIUM,    COXFUSIOX,    STUPOR  55 

In  the  larger  number  of  cases  a  mild  excitation  or  depression 
is  present  during  the  early  subsidence  of  s\Tnptoms.  At  times, 
after  lucidity  has  made  its  appearance,  hallucinations  may  still 
be  evident,  but  they  are  not  pronounced  and  no  longer  form 
the  basis  of  delusions.  Gradually  they  also  disappear.  During 
convalescence  the  patient  is  often  irritable,  grumbhng,  and 
dissatisfied;  at  other  times  he  may  be  a  httle  distrustful  and 
suspicious.  Little  by  little,  however,  he  becomes  sensible,  more 
friendly,  and  manifests  confidence  in  those  about  him.  At 
the  same  time  that  these  mental  changes  are  obser\'ed,  it  is 
also  noted  that  the  patient's  physical  condition  is  improving. 
It  should  be  borne  ia  mind  that  at  this  stage  undue  strains 
or  emotional  excitement  may  retard  convalescence,  or  may 
even  induce  more  or  less  prolonged  relapses. 

The  duration  of  an  attack  of  confusion  of  the  active  form  is 
approximately  from  two  to  four  months;  rather  the  latter  than 
the  former,  and  often  longer.  IMental  weakness,  more  or  less 
marked,  may  persist  subsequently  for  some  time.  Exception- 
ally, many  months  or  even  a  year  or  more  may  elapse  before  a 
full  return  to  health  takes  place. 

Diagnosis. — The  diagnosis  of  the  active  form  is  readily  made. 
There  are  present  marked  confusion  approximating  at  times 
delirium,  marked  illusions  with  or  without  hallucinations, 
marked  restlessness  or,  at  other  times  and  less  frequently,  in- 
hibition of  movement. 

Prognosis. — Death  is  ver\'  infrequent;  notwithstanding,  it 
ma}^  occur,  due  at  times  to  extreme  exhaustion  and  at  others 
to  complications,  such  as  tuberculosis,  disease  of  the  heart 
or  other  \iscera,  sepsis  from  a  bed-sore  or  other  source  of 
infection. 


56  MENTAL    DISEASES 

PASSIVE    CONFUSION 

Confusion  does  not  always  present  itself,  as  already  stated, 
in  the  active  form  just  described.  Some  cases  are  so  slightly 
pronounced  that  merely  a  mild  confusion  is  noted,  illusions 
only  occasionally,  and  hallucinations  not  at  all.  As  in  the 
active  form,  however,  exhaustion  and  intoxication  appear  to  be 
the  basic  causes.  Indeed,  mild  confusion  is  so  often  symptom- 
atic of  exhaustion  plus  visceral  disease  that  its  occurrence 
should  always  suggest  the  latter.  It  may  be  purely  symptomatic 
of  general  causes,  such  as  the  exhaustion  of  overstrain,  shock, 
privation  and  exposure;  or  of  special  causes,  such  as  repeated 
and  excessive  hemorrhages,  of  gastro-intestinal  disorders,  of 
arteriosclerosis,  of  malignant  disease,  of  tuberculosis  or  other 
debihtating  conditions.  Concerning  this  interesting  and  im- 
portant subject,  the  reader  is  referred  to  Part  II,  Chapter  I. 
Mild  confusion  may,  in  contradistinction  to  active  confusion, 
be  properly  termed  passive  confusion,  as  has  already  been 
pointed  out.  It  is  necessarily  an  affection  of  variable  duration. 
As  before,  we  have  to  deal  with  toxicitj^  and  exhaustion,  and 
both  the  duration  and  the  degree  in  which  the  symptoms  are 
present  depend  upon  the  causes  at  work. 

Prognosis. — As  in  the  active  form  of  confusion,  the  mental 
sjTnptom-group  offers  of  itself  nothing  unfavorable.  When 
general  causes  alone  are  at  work,  the  prognosis  is  influenced  in 
part  by  the  degree  of  the  exhaustion.  When  due  to  special 
causes,  the  prognosis  is,  other  things  equal,  the  prognosis  of  the 
underljdng  affection. 

STUPOR 

Simple  stupor,  also  spoken  of  as  stuporous  insanity,  acute 
dementia,  or  curable  dementia,  is  a  form  closely  allied  to  con- 
fusion.    Indeed,  its  relation  to  confusion  is  so  intimate  that  it 


GROUP    I — DELIRIUM,    CONFUSION,    STUPOR  57 

may  with  justice  be  studied  under  the  head  of  confusion. 
However,  the  purposes  of  clear  clinical  conceptions  are  best 
served  by  a  separate  consideration. 

Stupor,  in  its  tj^ical  form,  is  characterized  by  an  abeyance 
of  the  mental  faculties.  This  abeyance  of  the  faculties  may 
be  complete  or  incomplete,  and  for  practical  purposes  stupor 
may  be  di^^ded  into  the  complete  and  incomplete  forms. 

Etiology. — The  etiology'  is  that  of  delirium  and  confusion. 
Again,  we  have  a  history  of  infection  and  exhaustion,  of  the 
exanthemata,  exhausting  fevers,  the  puerperium,  erysipelas, 
the  intoxications,  great  mental  or  physical  overstrain,  shock- 
fright,  etc.  "^Tay  in  a  given  case  these  factors  produce  con- 
fusion, and  why  in  another  they  produce  stupor,  we  can  only 
conjecture.  Doubtless  the  cause  is  to  be  sought  in  the  in- 
dividual susceptibility — i.  e.,  to  the  greater  or  less  degree  of 
the  resistance  offered  by  the  patient  and  to  the  intensity  of 
the  toxic  invasion. 

Symptoms  and  Course.- — Simple  stupor  does  not  make  its 
appearance  suddenly.  Usually  there  is  a  preliminary  period 
of  several  weeks'  duration,  during  which  the  patient  suffers 
from  more  or  less  marked  confusion.  Only  in  exceptional  in- 
stances is  this  period  short  or  relatively  short.  Rarely,  espe- 
cially in  cases  complicated  by  profound  shock,  or  in  which 
an  infection  or  intoxication  is  grafted  on  a  previously  exist- 
ing exhaustion,  the  preliminary  stage  of  confusion  lasts  but  a 
few  days. 

Early  in  the  attack  the  patient  suffers  from  insomnia,  is 
worried  and  afraid,  complains  of  headache,  inability  to  think. 
looks  ill,  is  weak,  loses  his  appetite.  Soon  mental  confusion 
makes  its  appearance.  The  patient  begins  to  lose  the  proper 
appreciation  of  his  surroundings,  believes  himself  to  be  in  a 
strange  place,  or  fails  to  recognize  the  people  about  him.     The 


58  MENTAL    DISEASES 

confusion  from  which  he  suffers  becomes  deeper  and  deeper, 
and  the  inability  to  appreciate  the  surroundings  becomes  more 
and  more  pronounced  until  he  lies  motionless  in  bed,  indifferent 
to  everjd^hing  about  him.  He  wnll  not  speak,  will  not  answer. 
His  surroundings  do  not  make  the  sUghtest  impression  upon 
him.  Emotionally  he  seems  placid  and  indifferent,  though  at 
times  sUght  signs  of  transient  emotional  disturbances — for 
example,  excitement,  depression,  weeping — may  be  noted. 
As  a  rule,  the  face  is  relaxed,  flaccid,  expressionless.  The  limbs 
he  in  the  positions  in  which  they  happen  to  be  placed.  The 
patient  lies  quite  still.  Often  he  remains  in  one  position,  or, 
if  placed  in  a  position  by  the  attendant  or  physician,  may  re- 
tain this  posture  for  a  time.  Fixed  positions,  or  automatism, 
are,  however,  not  present  in  a  typical  degree  as  in  catatonia. 
CSee  Part  I,  Chapter  V.)  The  patient  is  quite  helpless;  often 
he  is  indifferent  to  the  bladder  and  bowels  and  soils  the  bed. 
Usually  the  bowels  are  constipated. 

The  surface  of  the  body  may  be  cool  and  the  extremities 
cold;  indeed,  the  body  temperature  may  be  subnormal. 
The  pulse  is  small  and  somewhat  slow.  The  face  is  pale  or  a 
Uttle  dusky,  and  there  may  be  slight  cyanosis  or  even  edema  of 
the  extremities.  Everything  indicates  a  loss  of  vasomotor  tone, 
a  loss  of  innervation,  great  exhaustion  of  the  nerve-centers. 
The  respiration  is  shallow,  though  the  rate  is  not  much  altered. 
There  may  be  considerable  loss  of  weight,  and  in  women  men- 
struation usually  ceases. 

The  course  of  simple  stupor  varies  but  little  for  a  long 
time.  Three  or  four  months,  and  often  a  much  longer  period, 
elapses  before  any  change  is  noted.  Sometimes  the  course  is 
exceedingly  prolonged;  as  in  a  patient  of  the  writer,  a  young 
woman,  who  became  stuporous  early  in  October,  remained  in 
this  condition  until  the  latter  part  of  the  follo^\ang  December, 


GROUP    I — DELIRIUM,    CONFUSION,    STUPOR  59 

when  she  became  relatively  normal  for  a  period  of  about  two 
weeks,  when  stupor  again  supervened  and  persisted  until  the 
latter  part  of  the  following  August. 

Convalescence  is  gradual.  We  first  notice  some  return  of 
expression  in  the  face,  perhaps  attempts  at  speaking  or  gestures, 
which  are  more  or  less  intelUgible.  As  a  rule,  the  improvement 
is  first  noticed  in  the  evenings,  is  somewhat  less  marked  in 
the  mornings,  and  then  gradually  grows  more  continuous. 
During  convalescence  it  is  noticed  that  the  patient  becomes 
readily  fatigued,  and  frequently  recurrences  of  confusion  are 
observed  under  such  circumstances;  as,  for  example,  when  the 
patient  attempts  a  rather  prolonged  conversation.  The  phys- 
ical signs  are  also  those  of  improvement;  there  is  a  gradual 
change  for  the  better  in  the  circulation,  in  the  color  of  the  sur- 
face, and  in  the  temperature  of  the  extremities.  There  is  also 
an  improvement  in  the  general  nutrition  and  an  obvious  gain 
in  weight. 

Diagnosis. — The  diagnosis  of  simple  stupor  is  not  difficult. 
There  is  present  the  history  of  a  pre^'ious  infection  or  toxic 
cause  with  exhaustion;  usually  there  is  the  history  of  the  de- 
velopment of  the  sjTnptom-group  in  the  convalescent  period 
of  a  fever,  or  other  factors  are  present,  as  already  outlined  in 
considering  the  etiology.  Simple  stupor  is  to  be  differentiated 
from  the  stupor  of  melanchoha  and  the  stupor  of  catatonia  by 
the  history,  and  in  part  by  the  symptoms.  In  stuporous 
melanchoha  there  is  alw^ays  the  period  of  invasion  -v^ath  the 
tj^pical  depression  (see  Part  I,  Chapter  IV)  and  seK-blame, 
w^hile  the  stuporous  condition  is  every  now  and  then  broken 
in  upon  by  periods  of  melanchoHc  agitation.  In  catatonic 
stupor  there  is  again  a  definite  history  of  a  special  sjonptom- 
group  preceding  the  development  of  the  stupor.  (See  Part 
I,  Chapter  V.)     The  stupor  itself  presents  rigidity,  fixation, 


60  MENTAL    DISEASES 

automatism  to  a  marked  degree,  and  there  are  present  from 
time  to  time  automatic  movements,  stereotypy,  verbigeration. 
Prognosis. — As  in  ordinary  confusion,  other  things  equal, 
the  prognosis  is  good.  This  is  true  of  the  great  majority  of 
cases.  Usually  also  the  recovery  is  complete,  mental  integrity 
being  fulty  restored.  Unhappily,  this  is  not  the  invariable 
result.  In  a  small  number  of  cases,  mental  weakness  persists  for 
many  months,  and,  indeed,  a  permanent,  though  slight,  mental 
impairment  may  be  established.  Rarely  this  mental  im- 
pairment is  pronounced,  and  may  even  assume  the  form  of  a 
terminal  dementia.  Such  a  result,  however,  is  very  exceptional, 
and  it  is  probable  that  in  such  cases  we  really  have  to  do  with  a 
stupor  complicating  a  dementia  praecox.  (See  Chapter  V.) 
Sometimes  also  visceral  complications  make  their  appearance 
and  determine  a  fatal  result,  though  this  also  is  rare.  At 
times  a  tuberculous  infection  becomes  apparent. 

INCOMPLETE  STUPOR 
Incomplete  stupor,  or  stupor  with  excitement,  differs  from 
ordinary  stupor  in  the  fact  that  the  stupor  is  less  profound, 
less  absolute,  and  that  symptoms  of  confusion  and  physical 
restlessness  are  added  to  the  clinical  picture.  It  is  really  a 
stuporous  confusion,  and  constitutes,  in  fact,  a  transition  be- 
tween ordinary  active  confusion  and  complete  stupor.  It 
begins  with  sleeplessness,  great  irritability,  disconnected  and 
excited  speech,  and  physical  restlessness,  while  hallucinations 
are  more  or  less  evident.  The  case  may  at  first  resemble  a 
dehrium  of  exhaustion  or  a  confusional  insanity,  but  in  a  short 
time  the  confusion  becomes  very  deep.  The  patient  is  soon 
unable  to  understand  the  simplest  questions,  and  at  an  early 
stage  loses  all  touch  with  his  surroundings.  As  in  ordinary 
stupor,  consciousness  soon  becomes  deeply  obscured.     Hallu- 


GROUP    I — DELIRIUM,    CONFUSION,    STUPOR  61 

cinations  cease  to  be  manifested.  Illusions  are  no  longer  formed, 
for  the  surroundings  are  not  interpreted  at  all.  As  in  complete 
stupor,  the  face  is  expressionless,  though  now  and  then  the  signs 
of  some  emotional  disturbance  are  noted.  The  patient  is 
restless,  tugs  at  his  bed-clothes,  makes  purposeless  movements, 
resists,  perhaps  clings  to  surrounding  objects,  or  may  for  short 
periods  assume  fixed  positions.  The  general  physical  signs 
and  general  bodily  conditions  are  those  observed  in  pimple 
stupor  and  need  not  be  rehearsed.  As  a  rule,  the  administra- 
tion of  food  is  difficult  because  of  the  motor  excitement,  and 
sleeplessness  may  also  be  a  marked  feature. 

The  course,  duration,  and  prognosis  of  incomplete  stupor  do 
not  differ  materially  from  those  of  ordinary  stupor.  After  the 
lapse  of  months — three,  four,  or  more — there  is  a  gradual  re- 
turn of  an  appreciation  of  the  surroundings  and  generally  a 
recovery.  The  facts  already  stated  in  regard  to  ordinary 
stupor  apply  equally  here. 


CHAPTER  IV 

GROUP  n— MELANCHOLIA,  MANLA.,  CIRCULAR  IN- 
SANITY (MELANCHOLIA-MANIA;  MANIC-DEPRES- 
SIVE INSANITY) 

As  already  pointed  out  in  the  chapter  on  Classification 
(p.  30),  we  have  in  Group  II,  melancholia,  mania,  and  circular 
insanity,  forms  of  mental  disease  in  which  the  individual  attacks 
are  characterized,  in  general  terms,  by  the  following  features: 
first,  an  emotional  state,  either  of  depression  or  of  expansion^ 
which  dominates  the  entire  clinical  picture  and  outweighs 
all  other  symptoms;  second,  a  wave-like  course  of  gradual  in- 
crease, maximal  intensity,  and  final  subsidence.  The  widely 
differing  pictures  of  melancholia  and  mania  are  but  expressions 
of  one  and  the  same  clinical  entity.  Both  phases,  as  will  become 
apparent  later,  present  the  special  features  of  an  inherent 
neuropathy.  In  keeping  with  this  fact,  it  is  to  be  noted  that 
heredity  plays  an  important  role;  the  larger  number  of  cases — 
estimated  by  Kraepelin  at  80  per  cent.,  and  which,  if  the  truth 
were  known,  is  probably  much  larger — present  a  history  of 
melancholia-mania  or  other  forms  of  insanity  or  neuropathy  in 
the  ancestry.  Again,  melancholia-mania,  as  also  pointed  out 
in  the  chapter  on  Classification,  is  apt  to  occur — though  by  no 
means  always — in  individuals  of  mobile  and  temperamental 
extremes,  i.  e.,  in  persons  who  are  emotional,  readily  depressed 
or  excited,  or  who  are,  it  may  be,  given  to  poetic  or  artistic 
ideas  and  day-dreams.  This  does  not  imply,  of  course,  that 
persons  who  happen  to  possess  the  last-mentioned  qualities 
are  necessarily  neuropathic  or  abnormal,  for  if  this  were  the 

62 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY       6S 

case,  some  of  the  world's  greatest  achievements  in  literatm"e, 
art,  and  science  would  have  to  be  looked  upon  as  pathologic. 
It  is,  however,  quite  a  usual  experience  to  meet  with  persons 
of  the  temperament  here  outlined,  i.  e.,  the  manic-depressive 
temperament,  who  make  attempts,  artistic,  literary,  or  scien- 
tific, but  which  frequently  come  to  naught  because  of  inherent 
weakness,  impracticability,  or  some  other  essential  defect. 

Melancholia-mania  occurs  most  frequently  in  youth  and  early 
adult  life,  i.  e.,  about  the  third  decade;  or,  more  broadly  speak- 
ing, between  eighteen  and  thirty  years  of  age.  It  is  not,  of 
course,  limited  to  this  period,  but  may  occur  much  later  and, 
very  rarely,  earher.  However,  it  occurs  with  especial  frequency, 
as  just  stated,  in  the  third  decade  of  life.  This  period,  we  should 
remember,  is  one  during  which  the  transition  from  youth  to 
adult  Hfe  takes  place,  and  is  peculiarly  subject  to  emotional 
upheavals,  to  emotional  stress,  and  strain.  The  immature 
feelings  of  youth  give  place  to  serious  love  affairs,  Tilth  their 
attendant  perturbations;  the  day-dreams  of  the  boy  to  the 
ambitions  and  aspirations  of  the  man.  It  is  an  age  of  expan- 
sion, pleasure,  and  happiness,  but  also  of  depression  and  of 
suffering.  To-day  may  be  filled  vnXh.  the  promise  of  suc- 
cess, but  to-morrow  may  bring  the  realization  of  disappoint- 
ment. That  persons  who  are  the  victims  of  an  inherited  neu- 
ropathy— a  manic-depressive  insanity — should  manifest  their 
affliction  especially  at  this  period  of  life  is,  after  all,  not  sur- 
prising. The  individual  of  normal  constitution  passes  through 
this  period  unimpaired,  but  he  who  is  the  victim  of  the  manic- 
depressive  neuropathy  breaks  dowTi,  and  enters  either  upon  a 
depressive  or  expansive  wave,  or  perhaps  passes  through  a 
succession  of  both.  An  interesting  fact  to  be  mentioned,  is 
that  melancholia-mania  occurs  mor«  frequently  in  females 
than  in  males,  about  in  the  proportion  of  2  to  1. 


64  MENTAL    DISEASES 

Exciting  causes  are  of  doubtful  value,  though  it  is  believed 
that  profound  and  sudden  grief  or  other  emotional  overstrain 
may  in  some  cases  determine  an  onset.  In  the  vast  majority 
of  cases,  however,  such  factors  are  altogether  absent.  The 
usual  history  is  that  the  attack  of  melancholia  or  of  mania  has 
come  on  without  any  antecedent  cause;  there  has  been  nothing 
to  which  the  attack  could  be  ascribed.  This  is  what  we  would, 
of  course,  expect  in  an  affection  which  is  essentially  neuro- 
pathic and  hereditary.  It  hardly  seems  necessary  to  add  that 
melancholia,  mania,  and  circular  insanity  bear  no  relation 
to  trauma,  to  infection,  or  to  visceral  disease.  Unfortunately, 
in  text-books  upon  internal  medicine  the  statement  is  still 
occasionally  made  that  melanchoUa  or  mania  occur  as  sequelae 
of  this  or  that  form  of  fever  or  infection,  the  writer  not  having 
taken  the  care  to  differentiate  mere  states  of  delirium  with 
excitement  from  mania,  on  the  one  hand,  or  confusion  with 
depression  from  melancholia  on  the  other. 

Finally,  it  must  be  constantly  borne  in  mind  that,  as  already 
stated,  melancholia,  mania,  and  circular  insanity  constitute 
closely  related  forms  of  one  clinical  entity.  The  facts  upon 
which  this  conclusion  depends  had  best  be  enumerated  after 
the  various  forms  have  been  studied.  The  term  "manic-depres- 
sive insanity,"  introduced  by  Kraepelin,  has  been  largely 
accepted,  and  is,  on  the  whole,  to  be  preferred  to  the  more 
awkward  expression   "melancholia-mania." 

MELANCHOLIA 
Melancholia  may  be  defined  as  a  form  of  insanity  in  which 
the  essential  and  characteristic  feature  is  a  depressed  and 
painful  emotional  state,  more  or  less  persistent,  and  pursuing, 
other  things  equal,  a  wave-Uke  course.  There  is  also  present 
an  abnormal  inhibition  of  the  mental  and  physical  activities. 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      65 

Etiology. — The  facts  of  heredity  need  not  again  be  rehearsed. 
Suffice  it  to  say  that  they  apply,  it  would  appear,  with  especial 
force  to  melancholia.  Similar  remarks  apply  also  to  the  ques- 
tion of  individual  predisposition.  Melancholia  is  apt  to  occur 
in  persons  of  a  timid,  repressed,  reserved,  and  introspective 
temperament.  Again,  while  melancholia,  like  mania,  occurs 
by  preference  in  the  third  decade  of  life,  it  also  occurs  at  other 
ages.  Notably  is  it  met  with  at  the  middle  period  of  life,  and 
is  then  often  spoken  of  as  the  melancholia  of  middle  age  or  the 
melancholia  of  involution.  There  has  been  a  tendency  on  the 
part  of  many  alienists,  following  the  lead  of  Kraepelin,  to  make 
of  this  form  of  melancholia  a  separate  clinical  entity,  a  position 
which  the  facts  do  not  justify.  However,  a  brief  separate  con- 
sideration is  accorded  it  in  Part  II,  Chapter  II. 

Little  is  known  of  exciting  causes  in  melancholia.  Pro- 
found grief  or  violent  emotions  have  at  various  times  been  sup- 
posed to  play  a  role;  similar  is  it  with  excessive  fatigue  and 
long  continued  depressing  surroundings.  However,  patients 
are  met  with  continually  in  whom  no  such  factors  have  been 
present,  and  in  whom  the  melancholia  has  appeared  without 
any  antecedent  circumstances  of  significance. 

Symptoms  and  Course, — MelanchoUa,  as  we  shall  see,  pre- 
sents itself  in  a  number  of  forms.  It  is  the  simple  acute  form 
which  will  first  claim  our  attention.  Here  the  course  of  an 
attack  can  be  conveniently  divided  into  three  periods:  first, 
the  prodromal  period  or  period  of  evolution;  second,  the  period 
of  full  development;  third,  the  period  of  subsidence. 

The  prodromal  period  varies  somewhat  in  different  cases. 
In  the  larger  number,  however,  the  onset  is  exceedingly  slow. 
Weeks  and  months  may  elapse  before  the  affection  is  estab- 
lished. Occasionally,  however,  the  onset  is  relatively  rapid, 
and,  indeed,  at  times  it  seems  to  be  sudden.     Statements  as  to 


66  MENTAL    DISEASES 

the  latter  mode  of  onset,  however,  I  am  convinced,  are  often 
due  to  faulty  observation,  the  patient  not  having  attracted 
the  attention  of  his  friends  or  of  those  about  him  until  the  sjTnp- 
toms  had  already  attained  a  certain  degree  of  severity.  A 
sudden  onset  is  more  frequently  ascribed  to  cases  of  hypo- 
melancholia,  but  both  the  fact  and  its  significance  are  open  to 
question. 

In  the  ordinary  acute  form  it  is  usually  observed  that  the 
patient  is  nervous,  easily  depressed,  emotionally  easily  dis- 
turbed, and  inclined  to  worry.  The  appetite  is  diminished. 
The  nutrition  is  impaired.  There  is  gastro-intestinal  atony, 
a  coated  tongue,  perhaps  a  gastric  catarrh,  constipation.  The 
patient  suffers  from  headache — vague,  diffuse,  not  severe.  He 
may  complain  of  tinnitus.  He  does  not  sleep  well;  indeed, 
disturbed  sleep  or  insomnia  sooner  or  later  become  features  of 
the  case.  There  is  a  general  malaise,  a  sense  of  weakness,  an 
inability  for  exertion — a  more  or  less  marked  loss  of  energy. 
The  patient  loses  his  color,  the  vascular  tension  falls,  though 
the  pulse-rate  may  not  be  much  affected;  occasionally  attacks 
of  palpitation  are  noted.  Gradually  the  tendency  to  worry 
becomes  more  pronounced.  The  patient  at  first  is  apt  to  worry 
in  regard  to  miscellaneous  matters;  it  may  be  about  business 
happenings,  family  affairs,  about  his  health,  and  later — and 
this  is  of  great  significance — about  his  past  conduct.  Up  to 
this  time  the  patient's  mind  is  entirely  clear;  •  it  does  not  occur 
to  friend  or  relative  that  the  patient  is  suffering  from  anything 
but  a  mild  indisposition  -uathout  much  importance;  least  of  all 
is  it  suspected  that  he  is  developing  a  serious  mental  disease. 

Gradually  the  symptoms  become  accentuated ;  the  depression 
becomes  gradually  more  and  more  pronounced,  until  it  finally 
becomes  fixed  and  unchangeable,  and  then  constitutes  the  domi- 
nant feature  of  the  case. 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      67 

In  the  fully  developed  period  the  term  ''mental  depression" 
is  wholly  inadequate.  The  picture  presented  is  that  of  psychic 
pain,  psychic  suffering.  That  it  varies  in  degree,  in  intensity, 
in  different  cases  goes  without  saying.  That  it  is  a  ''pain" 
that  is  different  from  others  that  human  beings  are  capable 
of  feeling  is  extremely  probable.  It  would  seem  that  in 
some  patients  the  suffering  corresponds  to  the  painful  emotions 
experienced  when  normal  persons  are  sad  or  are  suffering  from 
sorrow  or  from  grief,  but  in  others,  and  unhappily  in  the  larger 
number,  the  pain  is  more  intense,  and  appears  to  be  in  the 
psychic  world  of  feelings  what  trigeminal  neuralgia  is  in  the 
physical.  Doubtless  it  was  some  such  thought  as  this  that 
prompted  Clouston  to  term  this  condition  "psychalgia." 

The  attitude,  the  expression,  and  the  words  uttered  are  all 
indicative  of  mental  pain  and  suffering.  The  face  is  pale  and 
its  features  drawn  and  distorted,  as  though  by  sorrow,  grief, 
despair,  hopelessness.  The  head  is  bowed,  the  shoulders 
drooping,  the  arms  hanging,  the  whole  attitude  one  of  listless- 
ness  and  dejection.  The  patient  is  quiet,  sits  still,  remains 
apart  and  by  himself,  evidently  wishes  to  be  let  alone.  Fre- 
quently he  will  not  talk.  When  spoken  to  or  perhaps  brusquely 
disturbed  he  may  weep.  If  he  does  speak,  we  may  find  that 
his  voice  is  low,  that  his  speech  is  hesitating,  his  manner 
abstracted,  or,  it  may  be,  that  he  will  tell  of  the  sin  he  has 
committed,  of  his  moral  worthlessness,  of  the  hopelessness  of 
the  future. 

We  note  that  he  speaks  slowly,  that  his  thoughts  are  retarded, 
that,  in  addition  to  his  physical  inhibition,  there  is  also  an  in- 
hibition of  cerebral  activity.  In  some  cases  this  symptom  be- 
comes very  marked.  He  then  talks  very  httle,  the  speech  is 
slow,  often  limited  to  a  few  words  and  short  phrases,  and  even 
these  are  uttered  as  though  the  patient  unloaded  them  with  an 


68  MENTAL    DISEASES 

effort.  In  keeping  with  this  is  also  the  fact  that  cases  of  melan- 
cholia write  very  few  letters. 

Added  to  the  cardinal  symptom  of  psychic  pain  there  are,  as 
already  hinted,  delusions.  These  delusions  are  unsystematized 
or  feebly  systematized,  and  are  always  of  a  painful  and  of  a 
depressive  nature.  The  patient  believes  that  he  is  in  a  state 
of  moral  worthlessness,  moral  ruin,  that  his  soul  is  hopelessly 
lost,  that  he  cannot  be  saved.  There  arises  in  the  great  ma- 
jority of  cases  a  delusion,  known  technically  as  the  "delusion 
of  the  unpardonable  sin."  Some  act  of  the  patient's  past, 
often  trivial  and  inconsequential,  may  be  taken  up  and  con- 
strued as  a  sin,  a  crime  that  cannot  be  undone,  that  cannot  be 
atoned  for.  Most  frequently  the  delusion  relates  to  some  en- 
tirely imaginary  experience.  Thus  a  woman  of  unimpeachable 
virtue  may  beUeve  that  she  has  sacrificed  her  chastity;  a  man 
of  unimpeachable  character,  that  he  has  been  hopelessly  wicked. 
The  patient  constantly  reproaches  himself.  He  has  brought 
misery  and  suffering  upon  others,  has  ruined  and  disgraced  his 
family,  has  hopelessly  offended  God,  he  can  never  be  forgiven, 
his  soul  is  lost,  endless  pain  and  punishment  he  before  him. 
He  is  fearful  and  timid,  sometimes  believes  that  he  is  in 
prison,  or  that  he  is  to  be  executed  for  some  crime. 

The  delusions  of  melancholia  are  always  characterized  by  the 
fact  that  the  patient  invariably  refers  the  cause  of  his  suffering 
to  himself.  It  is  always  himself  who  is  to  blame.  It  is  always 
himself  who  has  wrought  the  ills  from  which  he  suffers,  who 
has  caused  misfortune  and  pain  to  others.  He  alone  is  the 
author  of  the  terrible  situation  in  which  he  finds  himself.  Even 
when  he  beheves  that  he  is  being  punished  by  others,  is  being 
poisoned,  tortured,  eviscerated,  sentenced  to  death,  it  is  always 
a  punishment  which  he  has  brought  upon  himself,  a  punishment 
which  is  being  inflicted  upon  him  justly  and  which  is  the  result  of 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      69 

his  own  acts.  The  delusions  are  never  truly  persecutory,  always 
self-accusatory,  and  this  constitutes  a  most  important  point  in 
the  differentiation  of  melancholia  from  the  depressive  phases 
of  the  paranoid  states;  in  the  latter,  as  we  will  see,  the  patient 
always  seeks  for  the  explanation  of  his  suffering  in  the  outside 
world. 

As  has  already  been  stated,  the  patient  talks  very  little,  and 
then  only  about  his  terrible  phght.  It  is  the  constantly  re- 
curring stor}^  of  his  self -blame;  the  delusive  tale  is  told  again 
and  again,  and  always  -^dth  the  same  conviction  of  its  truth 
and  reahty.  He  is  not  sick,  he  does  not  require  a  doctor,  he 
has  simply  been  wicked,  hopelessly  "kicked.  At  times  the  pa- 
tient cannot  be  made  to  talk  at  all,  but  will  merely  sit  and  moan; 
sometimes  he  gives  vent  to  cries  and  lamentations.  At  others 
he  will  repeat,  in  tones  of  monotonous  suffering,  the  same  phrase 
or  expression  as  did  one  of  my  patients,  a  woman,  who 
suffered  from  the  delusion  of  violation  of  chastity.  She 
would  for  hours  repeat  in  inexpressible  anguish  the  phrases 
"If  I  had  only  said  'no!'  said  'no!'  said  'no!'  "  So  great  and 
long  continued,  so  distressing  were  these  lamentations,  that 
they  constituted  a  severe  strain  upon  her  nurses. 

In  the  acute  form,  the  form  which  we  are  here  considering, 
hallucinations  are  also  prominent;  indeed,  they  are  very  fre- 
quent. Quite  commonly  they  consist  of  hallucinations  of 
hearing.  The  patient  hears  voices,  curses,  and  cries,  words  of 
reproach,  is  told  of  his  crimes,  of  his  sins.  Sometimes  the  pa- 
tient hears  the  cries  and  shrieks  of  others — men,  women, 
children — whose  suffering  he  has  brought  about. 

In  pronounced  cases,  though  less  frequently,  hallucinations 
of  sight  may  also  be  present.  The  patient  suffers  from  horrible 
visions,  sees  phantoms,  death's  heads,  scenes  of  suffering,  blood, 
massacres,   people  being  burned  ahve.      At   such  times   the 


70  MENTAL    DISEASES 

visual  and  auditory  hallucinations  seem  to  be  associated  and 
combined. 

Hallucinations  of  taste  and  smell  can  also  be  recognized  as 
existing  in  some  cases.  As  in  hallucinations  of  sight  and  hear- 
ing, they  are  always  painful,  and  consist  of  bad  odors  and  dis- 
gusting tastes.  Very  frequently,  also,  illusions  of  taste  and 
smell  are  present.  The  food  tastes  horribly,  it  is  decomposing, 
putrescent,  consists  of  urine  and  feces,  the  flesh  of  corpses. 

Visceral  hallucinations  and  general  or  local  somatic  hallu- 
cinations referred  to  this  or  that  part  of  the  body,  to  the  surface, 
to  this  or  that  organ,  are  present  in  varying  degree  in  different 
cases.  They  are  always  distressing  and  painful  in  nature,  and 
doubtless  enter  into  beliefs  of  torture,  suffering,  and  punish- 
ment. 

A  few  additional  facts  as  to  the  condition  of  patients  in  the 
fully  developed  period  of  melancholia  deserve  to  be  mentioned : 
First,  the  patient's  distress  and  delusions  are  concerning  him- 
self; as  regards  others,  relatives  and  friends,  he  is  apathetic 
or  indifferent;  indeed,  sometimes  he  shows  aversion.  Rarely 
does  he  manifest  anxiety  in  regard  to  others,  and  then  usually 
only  when  the  latter  are  in  some  way  entangled  in  his  delusions. 
His  indifference  extends  also  to  his  surroundings,  to  his  per- 
sonal appearance,  and  to  his  dress. 

Second,  the  visceral  signs  of  the  initial  stage  become  in  the 
fully  developed  period  accentuated.  Every  symptom  points 
to  a  pronounced  loss  of  nervous  tone,  to  a  defective  innerva- 
tion. There  is  now  a  marked  gastro-intestinal  atony.  The 
Ups  and  mouth  are  dry,  the  tongue  is  white  and  pasty,  the  saliva 
scanty  and  thick,  and  there  is  marked  fetor  of  the  breath. 
Often  there  is  present  an  acid  indigestion.  Almost  always 
there  is  present  a  severe  and  sometimes  obstinate  constipation. 
The  loss  of  appetite  is  now  very  profound.     The  patient  may 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      71 

experience  a  veritable  disgust  or  fear  of  food.  This  symptom 
is  frequently  spoken  of  as  sitiophobia.  Sometimes  he  enter- 
tains the  delusion  that  it  is  wicked  for  him  to  eat  or  that  God 
has  forbidden  him  to  eat. 

The  circulatory  apparatus  also  reveals  changes.  The  force 
of  the  beat  of  the  heart  is  lessened,  the  arterial  tension  lowered. 
The  surface  of  the  body  is  pale,  the  extremities  are  cold,  and 
their  distal  parts  are  often  dusky  or  cyanosed;  even  slight 
puffiness  or  edema  may  be  noted.  The  pulse-rate  is  not  much 
changed;  quite  frequently  it  is  a  little  slower  than  normal; 
at  other  times,  under  circumstances  to  be  considered  later,  it 
is  increased.  The  temperature,  more  especially  the  surface 
temperature,  may  be  distinctly  subnormal;  more  particularly 
is  this  true  in  cases  which  pass  into  the  stuporous  form. 
The  blood  shows  some,  though  not  marked,  diminution  in 
the  erythrocytes  and  also  in  the  percentage  of  hemoglobin. 
D'Abundo  believes  that  its  bactericidal  activity  is  lessened. 

The  respiration,  with  certain  exceptions  to  be  noted,  is  some- 
what slower  and  somewhat  shallower  than  normal. 

The  urine  is  usually  lessened  in  amount;  its  specific  gravity 
is  frequently  increased,  though  it  may  be  diminished.  It  also 
appears  to  have  a  higher  coefficient  of  toxicity  than  normally. 
The  proportion  of  phosphates  varies  somewhat;  the  earthy 
phosphates  are  increased,  the  alkaline  phosphates  diminished. 
The  output  of  nitrogen,  as  one  would  almost  expect,  is  lessened. 

The  skin  is  abnormally  dry  and  the  hair  brittle.  The  per- 
spiration is  usually  much  diminished.  Owing  doubtless  to  the 
lessened  amount  of  fluid  in  the  tissues  of  the  skin,  the  electric 
resistance  of  the  latter  is  increased. 

The  loss  of  weight  noted  in  the  initial  period  is  more  pro- 
nounced in  the  fully  developed  period.  In  women  menstru- 
ation becomes  scanty,  irregular,  and  quite  commonly  ceases. 


72  MENTAL    DISEASES 

From  the  strictly  neurologic  point  of  view  the  patient  pre- 
sents but  few  symptoms.  The  muscles  lack  tone,  the  patient 
is  physically  weak.  The  reflexes,  save  during  periods  of  ex- 
citement, reveal  no  changes  of  moment.  The  cutaneous  sen- 
sibility appears  to  be  lessened,  though  this  may  be  due  to  the 
mental  state.  The  same  appUes  also  to  the  special  senses. 
They  reveal  no  physical  signs.  The  sphincters  are  normal. 
Sexually  the  patient  is  indifferent. 

An  all-important  fact  to  bear  in  mind  in  regard  to  melan- 
cholia is  the  tendency  to  suicide.  This  is  present  in  practically 
every  case,  a  point  that  cannot  be  too  strongly  insisted  upon. 
At  times  it  is  but  slightly  marked ;  indeed,  it  may  be  denied  by 
the  patient.  The  latter  may  say  that  life  no  longer  holds  any- 
thing for  him,  that  he  might  as  well  be  dead,  yet,  in  reply  to 
questions,  he  may  answer  that  he  has  never  thought  of  killing 
himself.  Quite  commonly  when  the  patient  makes  this  state- 
ment I  am  convinced  that  he  is  attempting  a  deception; 
he  dreads  the  supervision  and  possible  restraint  which  the  ad- 
mission might  entail.  More  dangerous  to  the  successful  con- 
duct of  such  a  case  is  the  fact  that  relatives,  often  a  mother, 
wife,  or  sister,  flouts  the  idea  of  suicide  and  prevents  the  insti- 
tution of  protective  measures  until  too  late,  or  interferes  with 
such  measures  after  they  have  been  instituted,  with  fatal  con- 
sequences. Thus,  a  mother  withdrew  her  daughter  from  an 
asylum ;  death  by  pistol  wound  on  third  day.  A  wife  withdrew 
her  husband  from  the  watchful  care  of  an  attendant  and  en- 
couraged him  to  resume  his  business;  death  on  seventh  day 
from  gunshot  wound  of  head.  Every  alienist  can  cite  such 
experiences. 

The  methods  which  patients  adopt  depend  somewhat  upon 
the  individual  case,  the  opportunities  presented,  the  nature  of 
the  delusions,  and  whether  or  not  the  patient  is  under  super- 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      73 

vision  and  the  character  of  that  supervision.  Among  the 
methods  adopted  are  asphyxiation  with  illuminating  gas, 
swallowing  laudanum  or  other  poison,  inhalation  of  chloroform, 
hanging,  strangulation,  cutting  the  throat  with  a  razor,  death 
by  firearms,  drowning,  leaping  from  a  height  or  head  foremost 
from  a  window,  swallowing  broken  glass,  wounds  with  cutting 
instruments,  knives,  and  scissors. 

Sometimes  the  patient  adopts  some  particularly  horrible 
method,  as  in  the  case  of  a  woman  who,  being  ill-advisedly  re- 
moved from  the  asylum  by  her  relatives,  burned  herself  to  death 
at  her  own  home.  It  would  appear  that  such  methods  are  in 
keeping  with  or  suggested  by  the  punitive  character  of  the 
delusions  which  these  patients  frequently  entertain. 

Sometimes  the  attempts  at  suicide  are  wholly  inadequate  and 
the  methods  trivial,  absurd,  or  childish;  as,  for  instance,  the 
chewing  and  swallowing  of  paper,  trying  to  open  an  artery  with 
a  pin,  or  the  tying  of  a  handkerchief  or  cord  around  the  neck, 
but  with  insufficient  force  to  do  any  harm.  Patients  quite 
frequently  lack  the  decision  and  determination  to  carry  out  the 
suicide  which  they  have  planned;  especially  is  this  the  case  if 
the  method  requires  strength,  force  of  will,  or  sustained  effort, 
as  in  self-strangulation.  And  yet  patients  who  now  and 
then  fail  with  one  method  are  often  successful  with  another,  as 
in  the  case  of  a  patient  who  failed  to  prick  her  temporal  artery 
with  her  hat  pin,  but  subsequently  shot  herself  through  the 
heart.  It  is  the  sudden  leap  into  the  water,  the  leap  from  the 
window,  the  pistol  shot — the  act  that  requires  but  the  moment- 
ary rather  than  the  continuous  effort — that  is  so  often  chosen. 
A  method  that  patients  often  persist  in  for  a  time,  and  which, 
but  for  intervention,  would  occasionally  be  successful,  is  star- 
vation. Because  of  the  loss  of  appetite  and,  indeed,  actual 
disgust  for  food  so  markedly  present  in  the  average  case,  the 


74  MENTAL    DISEASES 

patient  often  abstains  from  food  spontaneously,  and,  if  the 
sitiophobia  appears  to  be  associated  with  the  delusion  already 
mentioned  that  it  is  wTong  for  him  to  eat,  he  may  readily  drift 
into  starvation  as  a  means  of  self-destruction;  it  requires  no 
effort  on  his  part,  merely  a  passive  acquiescence. 

MELANCHOLIA    WITH    AGITATION 

The  picture  of  melancholia  thus  far  outlined  is  that  of  the 
ordinary  acute  form.  Stress  has  been  laid  upon  the  fact  that 
the  patient  moves  but  little,  that  he  tends  to  remain  quiet  for 
long  periods  of  time,  often  in  the  same  position,  that  his  speech 
is  slow,  and  that  his  thoughts  are  retarded.  The  picture  is 
often  one  of  marked  mental  and  physical  inhibition.  However, 
the  attack  does  not  always  present  itself  in  this  form.  Every 
now  and  then,  a  case  is  met  with  in  which  the  quiet  is  broken  in 
upon  by  periods  of  agitation.  The  agitation  is  at  times  pre- 
ceded by  a  premonitory  restlessness;  more  frequently,  how- 
ever, it  appears  as  a  sudden  outbreak.  During  the  attack  the 
patient  moans,  wrings  his  hands,  shrieks,  complains  of  his  ter- 
rible plight,  may  tear  his  clothing,  struggle  with  his  attendants, 
attempt  desperately  to  kill  himself.  At  times  the  attack 
amounts  to  a  veritable  frenzy,  the  so-called  "melancholic 
frenzy"  or  "raptus  melanchoUcus."  At  other  times  the  agitation 
is  less  intense;  the  patient  is  restless  and  disturbed,  terrified 
and  anxious,  moans  and  cries  out.  The  condition  may  persist 
for  some  time,  and  is  then  commonly  spoken  of  as  ''melan- 
choUa  agitata."  In  some  cases  of  melancholia,  agitation  never 
supervenes;  in  others,  agitation  occurs  in  episodes;  in  others 
still,  it  is  present  during  a  large,  a  major  portion,  or  even 
during  the  entire  attack.  The  transition  from  the  agitated  to 
the  quiet  phase  may  be  gradual;  sometimes  it  is  quite  rapid. 

After  the  fully  developed  period  has  lasted  for  a  time — 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      75 

usually  several  months — the  patient  begins  gradually  to  im- 
prove. His  depression  gradually  grows  less,  his  hallucinations 
disappear,  his  delusions  become  less  insistent,  he  begins  to  take 
more  food,  to  sleep  better,  to  gain  in  weight,  and  little  by  little 
convalescence  is  established.  He  again  becomes  cheerful,  and 
finally  reaches  a  normal  level.  As  a  rule,  the  symptoms  sub- 
side gradually.  Usually  the  memory  of  the  attack  is  more 
or  less  clouded  for  the  period  of  the  maximum  intensity  of 
symptoms. 

The  duration  of  an  attack  of  simple  acute  melancholia — 
i.  e.,  a  first  attack — is  about  four  months.  Rarely  is  it  less, 
and  not  infrequently  it  is  very  much  more. 

The  course  of  an  attack  of  melancholia  is  by  no  means  always 
uniform;  there  is  not  always  the  history  of  a  gradual  increase, 
a  maximum  and  a  gradual  subsidence  of  symptoms.  Some- 
times the  course  is  intermittent  and  irregular.  The  depression 
in  such  cases  is  not  uniform,  but  subject  to  sudden  lessenings 
and  sudden  exacerbations,  variable  alike  in  intensity  and  dura- 
tion. As  might  be  expected,  cases  with  an  irregular  course 
offer  a  less  hopeful  outlook  as  regards  the  individual  attack. 

Diagnosis. — The  diagnosis  of  melancholia  is,  as  a  rule,  not 
difl&cult.  The  history  of  a  gradually  oncoming  and  deepening 
depression,  the  self-accusatory  attitude  of  mind,  the  delusions 
of  self-blame,  of  the  unpardonable  sin,  the  evident  reference  of 
the  suffering  of  the  patient  to  himself,  leave  no  doubt  as  to  the 
nature  of  his  affection.  Little  excuse  can  be  given  for  con- 
founding such  a  case  with  the  symptom  group  of  the  fatigue 
neurosis,  neurasthenia  (see  Part  I,  Chapter  VI),  and  still  less 
for  mistaking  it  for  paranoia.  In  the  latter  affection  the 
patient  refers  his  sufferings  to  the  external  world,  and  seeks 
their  explanation  in  persecution  and  conspiracies. 

Prognosis. — The  prognosis  is  favorable  as  regards  the  indi- 


76  MENTAL    DISEASES 

vidual  attack  in  the  large  majority  of  cases.  However,  death 
from  exhaustion  every  now  and  then  occurs.  Sometimes,  too, 
visceral  complications  arise,  though  these  are  infrequent. 
Unfortunately  melancholia  is  an  affection  which  is  essentially 
recurrent,  and  which  bears,  in  indi\'idual  cases,  close  relations 
to  mania,  and  is,  indeed,  often  but  one  phase  of  a  larger 
affection,  circular  or  manic-depressive  insanity.  The  prog- 
nosis of  the  latter  affection  is  considered  as  a  whole  at  the 
close  of  the  present  chapter. 

HYPOMELANCHOLIA 

Melancholia  does  not  always  present  itself  in  the  form  here 
outlined.  Ever\'  now  and  then,  it  is  met  with  in  a  subacute  form, 
a  form  which  can  properly  be  termed  "hypomelancholia."  It 
then  presents  the  following  peculiarities:  In  mode  of  onset  it  is 
said  to  be  more  rapid  and,  indeed,  at  times  sudden,  though  this 
hardly  accords  with  the  experience  of  the  wTiter.  There  is 
again  a  painful  emotional  state,  long  continued,  but  which 
falls  below  that  of  typical  acute  melancholia  in  intensity.  Its 
degree  varies  in  different  cases  and  often  at  different  times  in 
the  same  case.  Sometimes  it  consists  merely  of  a  simple  pro- 
longed wave  of  depression;  at  others  it  is  more  marked,  and 
may  even  at  times  approximate  the  depression  of  ordinary 
melancholia.  Sometimes,  again,  episodes  occur  in  which  the 
depression  is  much  accentuated.  On  the  whole,  however,  it 
pursues  a  distinctly  milder  course. 

The  physical  and  psychic  inhibition,  noted  in  ordinary  melan- 
cholia, is  also  a  marked  feature  here.  The  patient  is  inactive, 
lacks  energy  and  initiative.  At  first  he  forces  himself  by  sheer 
effort  of  '^'ill  to  do  his  daily  work,  indeed,  to  perform  the  sim- 
plest duties.  Soon  he  puts  off  his  engagements,  defers  answer- 
ing his  letters,  becomes  more  and  more  indifferent  to  his  obU- 
gations,  and  finally  fails  utterly  to  meet  them.     He  avoids 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY.     77 

effort,  occupation,  society,  cannot  exert  his  will  to  meet  the 
ordinary  routine  of  his  daily  living;  remains  at  home,  perhaps 
in  bed,  incapable  of  effort. 

Though  the  psychic  suffering  is  not  as  acute  as  in  ordinary 
melancholia  the  attitude  of  mind  is  the  same.  The  patient 
worries,  blames  himself,  finds  fault  with  himself  because  of 
things  he  has  done  or  because  of  things  that  he  has  failed  to  do. 
His  ideas  may  acquire  all  the  force  of  delusions;  or  typical  de- 
lusions of  the  unpardonable  sin  may  develop.  Very  frequently, 
however,  when  delusions  are  present  they  are  somatic — i.  e., 
hypochondriac  in  character — the  patient  believes  that  he  is 
hopelessly  ill,  has  this  or  that  incurable  visceral  or  constitu- 
tional disease.  At  other  times,  his  ideas  are  religious,  and  then, 
as  before,  self-blame  and  hopelessness  play  the  essential  role. 
At  others  still,  though  much  less  frequently,  the  ideas  are  per- 
secutory, but  here  again  the  acts  of  his  friends  and  neighbors, 
the  various  things  that  are  being  done  to  him,  are  the  result  of 
his  own  conduct  and  he  himself  is  to  blame. 

Hallucinations  of  hearing  and  of  the  other  special  senses 
are  very  infrequent.  However,  somatic  hallucinations,  vague 
and  ill-dej&ned,  appear  to  be  present  in  many  cases,  and  doubt- 
less serve  as  a  basis  for  hypochondriac  ideas.  Sometimes 
there  is  a  general  feeling  of  bodily  illness,  a  general  cenesthetic 
hallucination. 

In  the  experience  of  the  writer  hypomelanchoUa  occurs  more 
frequently  among  men  than  among  women.  The  duration  of 
hypomelancholia  is,  as  a  rule,  very  prolonged.  The  altitude 
of  the  wave  is  less,  but  it  extends  over  a  relatively  longer  period 
of  time.  Sometimes,  as  we  will  see,  it  forms — as  may  ordinary 
melancholia — but  one  phase  of  a  larger  cycle.  Both  its  dura- 
tion and  its  outcome  are  matters  most  difficult  of  prognostica- 
tion. However,  it  can  be  safely  hazarded  that  the  patient 
will  after  many  months,  a  year,  a  year  and  a  half,  recover  from 


78  MENTAL    DISEASES 

his  attack,  but  whether  the  attack  will  be  followed  by  a 
period  of  lucidity  or  will  suffer  transition  into  a  phase  of  ex- 
pansion cannot  be  foretold. 

The  danger  of  suicide  in  hypomelancholia  deserves  a  word. 
In  my  experience  this  danger  is  decided.  The  patient's  lu- 
cidity is  frequently  so  pronounced,  he  is  relatively  so  clear,  that 
it  is  often  impossible — indeed,  impracticable — to  surround  him 
with  adequate  protection.  Commitment  can  only  rarely  be 
advised.  The  relatives  and  friends,  too,  as  a  rule,  scout  the 
idea  of  confinement  in  an  asylum.  The  patient  himself  rejects 
the  proffered  nurse  or  attendant.  It  is  not  surprising,  there- 
fore, that  under  these  circumstances  he  not  infrequently  kills 
himseK;  sometimes,  and,  indeed,  usually,  he  commits  the  act  in 
an  impulse  bred  of  an  accession  of  symptoms.  The  danger  is 
the  greater  because  the  true  nature  of  the  affection  is  not  always 
recognized.  Patients  suffering  from  hypomelancholia  every 
now  and  then  are  mistaken  for  cases  of  nervous  prostration, 
neurasthenia,  nervous  dyspepsia,  and  like  disorders. 

Finally,  some  patients  appear  to  be  in  a  condition  of  melan- 
cholic depression  throughout  the  greater  part  of  their  lives.  All 
of  their  thoughts,  acts  and  experiences  are  accompanied  by 
feelings  that  are  distressing  or  painful.  The  term  "constitutional 
emotional  depression"  adequately  describes  their  condition,  and 
their  cases  may  be  looked  upon,  in  a  sense,  as  representing 
the  underhing  neuropathy  of  which  the  frank  melanchoUc 
attack  with  its  wave-like  course  is  the  more  complete  expression. 

MELANCHOLIA    WITHOUT    DELUSIONS 

Melanchoha  occasionally  presents  itself  in  a  third  form — i.  e., 
an  attack  which  may  otherwise  resemble  a  typical  attack  of 
acute  melancholia,  or,  it  may  be,  of  hypomelancholia,  is  distin- 
guished by  the  fact  that  there  are  present  no  delusions  nor  any 
special  sense  disturbances,  neither  hallucinations  nor  illusions. 


GBOUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      79 

The  patient's  mind  is  entirely  clear.  There  is  present,  in  addi- 
tion to  the  physical  signs  of  exhaustion  and  depressed  nutrition, 
but  one  symptom,  namely,  that  of  mental  pain — i.  e.,  there  is 
present  a  psychalgia  and  nothing  more.  This  psychic  suffering 
may  be  relatively  mild,  but  more  frequently  it  is  intense  and 
may  attain  the  degree  of  severe  agony  or  of  exquisite  anguish. 
Such  patients  suggest  no  ideas,  no  explanations  as  to  their 
condition — i.  e.,  there  are  no  ideas  of  self-blame,  no  delusions  of 
the  unpardonable  sin,  no  delusions  of  bodily  illness;  merely  a 
persistent  suffering.  Not  infrequently  such  patients  become 
agitated  and  sit  for  hours  rocking  to  and  fro,  giving  vent  to 
constantly  repeated  moans  or  other  sounds  indicative  of  the 
great  distress  from  which  they  suffer.  Such  cases  are  spoken 
of  as  cases  of  melancholia  without  delusions,  melancholia  sine 
delirio,  or  lucid  melancholia.  As  in  other  forms  of  melancholia, 
there  is  a  danger  of  suicide.  This  danger,  as  in  hypomelancholia, 
is  somewhat  enhanced  by  the  fact  of  the  lucidity  of  the  patient 
and  the  consequent  difficulty  of  exercising  supervision.  Of 
course,  in  cases  in  which  the  suffering  is  so  great  that  the  pa- 
tient becomes  agitated  and  noisy  the  friends  more  readily 
consent  to  commitment  or  to  other  forms  of  protection. 

In  the  experience  of  the  wTiter,  while  the  course  of  lucid 
melancholia  is  that  of  a  gradual  increase,  maximum  intensity, 
and  gradual  subsidence,  the  duration  of  the  attack  is  usually 
very  prolonged;  many  months,  sometimes  years. 

MELANCHOLIA   WITH   STUPOR 

As  has  already  been  pointed  out,  the  patient  with  melan- 
cholia suffers  from  a  more  or  less  marked  inhibition,  both 
physical  and  psychic.  He  sits  quietly  by  himself,  will  not  move, 
will  not  talk.  In  some  cases  this  inhibition  becomes  so  pro- 
nounced that  he  sits  in  his  chair  or  crouches  in  a  comer  mute 
and  motionless,  as  though  spell-bound.     The  attack  begins. 


80  MENTAL    DISEASES 

as  a  rule,  like  an  ordinary  melancholia,  but  the  quiet  and  list- 
lessness  gradually  deepen  until  finally  the  patient  is  inert, 
immobile,  and  apparently  indifferent  or  oblivious  to  what  goes 
on  about  him.  He  may  sit  in  a  chair  with  his  chin  buried  in 
his  breast,  or  he  may  lie  motionless  in  bed.  The  features  are 
drawn,  contracted,  expressive  of  suffering.  The  pupils  are 
dilated  or  usually  so,  the  eyes  are  closed  or  the  Uds  are  droop- 
ing. The  patient  cannot  or,  at  any  rate,  does  not  speak, 
though  now  and  then  a  few,  usually  incomprehensible,  words 
issue  from  his  mouth.  If  he  be  placed  in  a  position,  perhaps  an 
awkward  or  uncomfortable  one,  which  under  ordinary  cir- 
cumstances readily  induces  fatigue,  the  position  may  be  main- 
tained for  a  long  time.  There  are,  however,  no  truly  cataleptic, 
no  catatonic,  symptoms  present.  Very  often,  indeed,  the 
patient  assumes  spontaneously  most  uncomfortable  attitudes, 
probably  as  a  result  of  his  delusions,  which  may  be  punitive  as 
well  as  painful.  As  in  other  forms  of  melanchoUa,  he  sleeps 
but  little,  and  may  be  found  at  night  half-seated  in  bed  or  in 
some  other  position  which  indicates  that  he  is  not  or  has  not 
been  sleeping.  The  temperature  is  sometimes  a  trifle  sub- 
normal; the  features  and  body  surface  are  pale;  sometimes 
there  is  a  moderate  degree  of  lividity  of  the  extremities;  the 
pulse  is  slow  and  small;  the  respirations  diminished.  The 
tongue  is  coated,  sitiophobia  very  marked,  constipation  ob- 
stinate. Cutaneous  sensibility  is  very  much  diminished;  that 
is,  the  mental  reaction  to  tactile  and  painful  stimulation  is 
diminished.  Every  now  and  then,  the  quiet  of  the  patient  is 
broken  in  upon  by  an  attack  of  agitation,  during  which  he  is 
more  or  less  disturbed,  is  restless,  cries  out,  and  moans.  Some- 
times the  phases  of  agitation  are  very  slight,  and  consist  in 
fitful  and  transient  changes  in  expression,  movements,  or 
whisperings.  In  some  cases,  again,  phases  of  agitation  are 
not  observed  at  all. 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      81 

This  form  of  melancholia  is  spoken  of  as  melancholia  with 
stupor  or  melancholia  attonita.  It  must  not  be  confounded 
with  the  stuporous  states  which  are  related  to  confusion  and 
delirium  or  which  are  observed  in  catatonia.  In  both  of  the 
latter  instances,  not  only  the  history  of  the  case,  but  also  the 
symptoms  present,  enable  a  ready  differentiation  to  be  made. 
During  the  period  of  subsidence,  the  patient  may  speak  of  his 
painful  feelings  and  suffering,  may  speak  of  his  delusions  of 
self-blame,  of  his  unworthiness,  of  his  sins,  and  in  this  way 
furnish  additional  evidence  of  the  nature  of  the  attack  through 
which  he  has  passed. 

As    a   rule,    melancholia    with    stupor    subsides   gradually, 

though  sometimes  it  does  so  rapidly.     The  duration  is,  as  a 

rule,  prolonged.     The  great  majority  of  cases  recover  from  the 

individual  attack,  though  the  prognosis  is  not  as  good  as  in  the 

ordinary  form.     Sometimes,  too,  there  are  severe  diarrheas; 

at  other  times,   the  exhaustion  is  so  profound  as  to  threaten 

death. 

MANIA 

Mania  may  be  defined  as  a  form  of  insanity  in  which  the 
essential  and  characteristic  feature  is  an  expansive  emotional 
state,  more  or  less  persistent,  and  pursuing,  other  things  equal, 
a  wave-like  course.  Not  only  is  the  emotional  state  the  reverse 
of  that  which  we  observe  in  melancholia,  but  this  is  true,  as  we 
will  see,  also  of  the  other  symptoms;  e.  g.,  instead  of  there  being 
a  general  mental  inhibition  and  slowing  of  thought,  there  is  here 
an  exaltation  of  the  mental  faculties,  an  abnormal  rapidity  in 
the  flow  of  ideas.  Similarly,  instead  of  physical  quiet  and  torpor, 
there  is  in  mania  physical  restlessness  and  activity.  In  other 
words,  along  with  the  expansion  there  is  a  general  release  of 
inhibition. 


82  MENTAL    DISEASES 

Etiology. — Little  need  here  be  repeated  as  to  etiology.  That 
which  applies  to  manic-depressive  insanity,  as  a  whole,  applies 
also,  of  course,  to  mania.  Suffice  it  to  say,  that  persons  who  are 
especially  disposed  to  manic  waves  are  thought  to  have  "ex- 
citable temperaments."  It  is  also  observed  that  they  react 
badly — i.  e.,  too  readily — to  stimulants,  or,  to  put  it  in  ordinary 
phraseology,  have  feeble  resistance  to  alcohol.  Again,  while 
occurring  by  preference  in  the  third  decade  of  life,  mania  may, 
like  melancholia,  occur  much  later.  Clinical  experience,  on  the 
whole,  shows  that  the  attacks  are  massed,  so  to  speak,  at  the 
early  period  of  Ufe,  and  that  they  occur  with  rapidly  diminishing 
frequency  as  middle  age  and  the  later  periods  of  life  are  ap- 
proached. 

As  in  melancholia,  exciting  causes  are  of  doubtful  value. 
Mental  and  emotional  overstrain,  sudden  shocks,  great  ex- 
citement, are  much  more  frequently  absent  in  the  clinical 
histories  than  present. 

Symptomatology  and  Course. — As  in  the  case  of  melancholia, 
the  simple  acute  form  first  claims  our  attention.  In  like 
manner  its  course  can  be  divided  into  three  periods:  first,  the 
prodromal  period  or  period  of  evolution;  second,  the  period  of 
full  development;  third,  the  period  of  subsidence. 

It  is  quite  common  to  speak  of  the  attack  as  beginning  with 
an  exaltation  or  expansion  which  gradually  or  rapidly  increases 
in  intensity.  However,  in  some  cases,  a  period  antecedent  to 
the  onset  of  expansion  is  observed  in  which  the  patient  is  de- 
pressed. This  period  is,  as  a  rule,  very  short,  a  few  weeks,  a 
few  days,  or  perhaps  only  a  few  hours.  Very  frequently  no 
history  of  this  antecedent  period  is  obtained,  and  perhaps  for 
the  reason  that  the  patient  has  not  been  under  observation. 
Under  average  conditions  little  attention  is  paid  by  relatives 
to  an  individual  member  of  the  family  unless  the  latter  pre- 
sents marked  or  striking  symptoms.     An  attack  of  pain,  an 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      83 

attack  of  fever,  of  delirium,  or  of  other  excitement,  will  at  once 
attract  attention,  but  the  vague  and  ill-defined  symptoms  of 
this  antecedent  period  are  of  such  a  character  as  may  readily 
escape  notice.  On  a  few  occasions  it  has  been  my  fortune  to  be 
summoned  during  this  period;  most  frequently,  however,  I 
have  not  been  called  until  manic  symptoms  were  in  frank  and 
full  development.  Sometimes  a  history  that  the  patient  was 
not  well  before  the  onset  of  the  excitement  can  be  obtained 
from  the  mother  or  other  close  or  intimate  relative  or  friend; 
at  other  times  the  inquiry  proves  futile.  We  are  frequently 
left  in  the  dark  as  to  the  detailed  personal  history  of  patients 
who  do  not  attract  attention  until  they  commit  some  overt 
act;  e.  g.,  in  paranoia,  in  which  affection  we  know  that,  despite 
the  frequent  paucity  of  evidence,  antecedent  symptoms  must 
have  long  been  present.  It  is  a  justifiable  position,  therefore, 
to  assume  that  in  mania  an  antecedent  period  of  depression  is 
more  often  present  than  actual  observation  would  indicate. 
Personally  my  feeling  is  that  such  a  period  always  exists, 
though  perhaps  this  is  going  too  far.  However,  there  is 
nothing  inherently  improbable  in  this.  Cases  of  mania  con- 
stantly occur  in  which  the  attack  frankly  follows  a  well- 
marked  and  typical  wave  of  melancholia,  thus  forming  a 
phase  of  the  cycle,  circular  insanity.  It  is  not  improbable 
that  the  preceding  depression  is  sometimes  very  mild  and  for 
this  reason  not  observed,  and  sometimes  also  very  short. 

What  are  the  symptoms  of  this  antecedent  period?  The 
patient  is  depressed,  nervous,  worried,  irritable.  He  cannot 
eat,  cannot  sleep,  complains  of  headache,  and  perhaps  of  other 
distressing  sensations;  has  indigestion,  constipation.  These 
symptoms  subside  rapidly,  it  would  appear,  and  are  replaced 
by  those  of  mania.  The  vague  sensations  of  depression  and 
discomfort  give  way  to  a  sense  of  well-being,  and  the  patient 
now  enters  into  an  expansive  state. 


84  MENTAL    DISEASES 

The  symptoms  that  supervene  are  the  opposite  of  those  ob- 
served in  melanchoha.  Instead  of  being  quiet  and  Ustless,  he 
is  now  restless  and  excited.  Instead  of  being  mute  or  chary 
of  speech,  he  is  now  talkative  and  even  noisy.  Emotionally 
and  intellectually  he  seems  as  though  exalted,  and  he  may  even 
appear  brilliant  when  compared  to  his  ordinary  self.  At  this 
time,  also,  a  man  who  is  usually  reserved,  quiet,  and  well  be- 
haved may  commit  venereal  and  alcoholic  excesses.  In  the 
early  period,  too,  the  patient  may  write  letters.  These  are 
exaggerated  in  style,  filled  with  exclamation  marks  and  numer- 
ous under  scorings,  and  often,  like  the  speech,  broken  and  un- 
intelligible. Soon  the  symptoms  become  more  and  more  pro- 
nounced, and  the  patient  enters  into  the  fully  developed  period 
of  his  attack. 

The  state  of  mind  in  mania  must  first  be  considered  in  order 
that  the  detailed  symptoms  may  be  properly  understood  and 
appreciated.  Few  if  any  Avriters  give  due  weight  to  the  funda- 
mental facts  of  the  manic  state,  and  content  themselves  with  a 
mere  recital,  a  clinical  portrayal,  of  symptoms;  but  this  hardly 
leads  to  adequate  conceptions  of  the  affection.  Further,  I 
have  for  many  years  believed  that  the  manic  state  could  not  be 
comprehended  unless  melancholia  were  studied  first;  depressive 
states  so  commonly  precede  the  evolution  of  mania  that  this 
sequence  of  study  seems  to  me  to  be,  also,  a  natural  one. 

It  has  just  been  stated  that  the  symptoms  of  mania  are  the 
opposite  of  those  observed  in  melancholia;  it  should,  with  em- 
phasis, be  added  that  the  underlying  states  upon  which  these 
symptoms  depend  are  exactly  opposite  to  each  other.  This 
statement  necessitates  a  brief  analysis.  To  repeat  a  cardinal 
fact,  there  is  in  melancholia  a  depression,  a  painful  emotional 
state,  a  psychalgia.  If  it  be  true  that  in  mania  we  have  an 
opposite  condition,  this  does  not  mean  that  this  opposite  con- 
dition is  joy,  happiness,  ecstasy;  indeed,  this  is  not  the  case, 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      85 

for  joy,  happiness,  and  ecstasy  impty  a  subjective,  an  egocen- 
tric, attitude  of  mind  just  as  much  as  do  the  depression,  the 
soul-ache,  the  psychalgia,  of  melanchoha.  The  mental  atti- 
tude of  mania  is  the  opposite  of  the  attitude  of  melancholia; 
it  is  objective;  it  concerns  itself  not  -udth  its  own  feelings, 
with  its  own  ego,  but  with  the  external  world.  There  is  no 
concentration  of  the  mind  upon  itseK  or  upon  its  own  pro- 
cesses, for  the  stream  of  thought  is  outward.  The  patient 
does  not  tell  us  how  he  feels;  he  does  not  say  "I  feel  well,  I 
feel  good,  I  feel  j&ne,"  but  we  infer  from  his  conduct  that  he  has 
a  sense  of  well-being.  He  is  boisterous,  boastful,  buoyant, 
acts  as  though  he  were  elated,  as  though  he  were  in  the  best 
of  spirits.  This  attitude,  or,  better  still,  this  tone  of  mind,  is 
closely  associated  -mth.,  indeed  part  of,  another  symptom, 
namely,  that  of  the  heightened  flow  of  thoughts  and  impulses. 
Here,  again,  we  have  a  second  fact  the  exact  opposite  of  that 
in  melanchoha.  In  melanchoha  thoughts  and  impulses  are 
inhibited;  their  flow  is  sluggish,  retarded,  restrained.  In 
mania  they  are  unrestrained  and  massive  in  number  and  may 
PQur  forth  Uke  a  torrent. 

With  these  two  facts  before  us,  let  us  turn  our  attention  to  the 
symptoms  more  in  detail;  and  we  will  assume  that  our  atten- 
tion is  directed  to  a  typical  acute  attack. 

The  patient,  as  already  indicated,  is  in  constant  motion;  his 
movements  are .  coarse  and  exaggerated,  his  gestures  extrav- 
agant. His  manner  is  aggressive,  his  expression  animated,  his 
color  heightened,  his  conjunctiva  tense  and  brilhant.  He 
laughs  and  frowns  in  quick  transition.  He  talks  incessantly. 
His  thoughts  flow  wdth  great  rapidity  and  he  constantly  gives 
vent  to  them.     His  style  is  boastful,  declamatory. 

In  keeping  vnth.  the  objective  mental  attitude,  he  rapidly 
embraces  the  objects  and  persons  in  a  room  in  the  scope  of  his 
perceptions,  but  fastens  his  attention  upon  nothing.      One  of 


86  MENTAL    DISEASES 

the  striking  features  of  mania  is  this  fault  of  the  attention.  It 
cannot  be  attracted  for  any  but  the  briefest  period  of  time.  It 
is  fleeting  and  fragmentary  in  the  extreme. 

Again,  so  rapid  and  hasty  are  the  acts  of  perception  that  the 
patient  constantly  makes  mistakes  as  to  the  identity  of  persons 
and  the  character  of  objects.  Strangers  may  be  greeted  as  old 
acquaintances,  addressed  by  familiar  names,  or  associated  with 
incidents  with  which  they  have  no  connection.  The  things 
about  the  patient,  too,  may  serve  to  evoke  numerous  and 
bizarre  ideas  with  which  these  objects  have  no  relation.  Illu- 
sions of  perception  thus  constantly  occur  and  are  more  frequent, 
it  would  appear,  as  regards  persons  than  as  regards  objects. 

The  significance  of  these  illusions  and  the  fictitious  memories 
they  arouse  becomes  apparent  as  we  listen  to  the  patient's 
speech.  Soon  we  become  aware  that  the  disturbed  mental 
processes  are  in  part  owing  to  an  increased  ease  and  rapidity 
of  association,  and  especially  to  an  association  that  is  unusual, 
bizarre,  often  frankly  abnormal.  Thus,  the  patient  sees  the 
doctor  or  an  attendant;  at  once  some  quality  or  number  of 
qualities  of  the  latter — e.  g.,  tone  of  voice,  attitude,  gesture, 
color  of  hair,  clothing,  or  what  not — evoke  in  the  patient's 
mind  associations,  multiple  and  crowded,  that  cause  the  patient 
to  mistake,  not  only  the  identity  of  the  person,  but  also  to  mis- 
place the  latter  altogether  in  time  and  place.  The  stranger  is 
spontaneously  associated  with  persons  the  patient  has  previously 
known.  Trains  of  ideas  are  thus  aroused  which  the  patient 
combines  with  the  individual  before  him.  Similarly,  every 
object,  the  surroundings,  the  room  in  which  the  patient  finds 
himself,  becomes  a  point  of  departure  for  equally  numerous 
and  abnormally  related  associations.  The  illusions  are  appar- 
ently due  in  part  to  the  fragmentary  and  imperfect  character 
of  the  perceptions  and  in  part  to  the  abnormal  associations 
aroused. 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      87 

The  associations  impress  one  as  striking,  unexpected.  Often 
they  seem  witty;  often  they  appear  as  attempts  to  rhyme,  to 
make  puns,  to  play  upon  words.  Further,  while  listening  to  a 
case  of  mania  we  are  impressed  with  the  enormously  increased 
flow  of  ideas,  but,  as  the  case  develops,  we  are  also  impressed 
by  the  changing,  evanescent,  unessential  character  of  the 
thoughts.  The  thoughts  are,  after  all,  not  so  rich  in  ideas 
as  in  words;  the  wonderfully  increased  association  is  found 
to  be  rather  the  association  of  coarse  quahties,  such  as  sounds, 
than  associations  of  meanings.  The  more  the  case  develops, 
the  more  evident  does  this  coarse  association,  especially  this 
'sound  association,  become.  The  supposed  exaltation  of  the 
mental  faculties  is  soon  found  not  to  be  genuine;  instead  a 
real  paucity  of  ideas  develops  which  becomes  more  apparent 
as  the  case  progresses;  and  the  seeming  richness  of  association 
often  degenerates  into  the  stringing  together  of  merely  similarly 
sounding  phrases,  words,  or  syllables. 

The  phenomenon  of  the  enormously  increased  association 
in  mania  is,  when  we  pause  to  reflect,  in  keeping  with  the  height- 
ened nervous  outflow.  It  is  legitimate  to  infer  from  the  in- 
tense motor  excitement,  the  restlessness  and  incessant  speech, 
that  nervous  discharges  pass  in  great  volume  through  the  effer- 
ent branches  of  the  neurones,  more  particularly  the  neuraxones, 
but  it  is  also  legitimate  to  infer  that  an  overflow  likewise  takes 
place  through  the  other  branches,  the  collaterals  and  dendrites. 
It  is  doubtless  upon  just  these  structures  that  association 
normafly  depends.  In  the  case  of  many  neurones,  all  of  the 
cell  processes  serve  this  function.  It  does  no  violence  to  the 
facts  to  suppose  that,  in  the  pecuhar  morbid  state  of  the  neural 
protoplasm,  nervous  energy  is  evolved  with  unusual  ease  and 
flows  with  lessened  resistance  along  the  cell  processes.  It  is 
doubtless  diffused  through  the  nerve  tissues  far  more  rapidly 


88  MENTAL    DISEASES 

and  readily  than  normally,  and  in  this  way  gives  rise  not  only 
to  the  motor  phenomena,  but  also  to  those  of  a  disturbed  asso- 
ciation. We  can  understand  why,  under  these  conditions,  the 
overflow  should  pass  along  unaccustomed  channels  and  thus 
give  rise  to  unusual,  to  bizarre,  to  pathologic  associations.  We 
can  also  understand,  perhaps,  why  the  associations  should  lose 
their  intimate,  elaborate,  and  finer  quahties;  why  they  should 
become  coarse  or  relatively  so.  Normal  acts  of  association  re- 
quire time,  and  probably  so  in  proportion  to  the  amount  of 
detail.  In  mania  such  acts  take  place  with  abnormal  speed 
and  in  abnormal  number.  The  discharges  are  doubtless  dif- 
fused en  masse,  and  probably  along  the  larger  pathways  in 
which  a  lessened  resistance  is  encountered.  Probably  upon 
these  facts  depend  the  coarseness  and  superficiality  of  the  asso- 
ciations. Fatigue  of  the  finer  collaterals  and  dendrites  may  also 
play  a  role,  so  that  as  the  case  progresses  coarse  and  flaring 
associations  only  are  presented. 

It  can  readily  be  understood  that  in  acute  mania  the  current 
of  ideas  is  never  uniform.  The  patient  is  incapable  of  carrying 
on  a  special  train  of  thought  or  gi\'ing  quiet  and  adequate 
consideration  to  SLuy  subject.  Indeed,  he  passes  with  leaps  and 
bounds  from  one  thing  to  another.  Soon  his  ideas  may  flow 
so  rapidly  that  his  speech  can  no  longer  keep  pace  with  them. 
He  jumps  from  one  sentence  into  another;  passes  from  phrase 
to  phrase,  word  to  word.  It  cannot  be  surprising  that  under 
these  circumstances,  due  to  the  inconstancy,  the  non-con- 
secutive character  of  his  thoughts,  the  disturbance  of  associa- 
tion and  the  speed  of  his  utterance,  that  he  becomes  incoherent; 
what  we  hear  may  be,  and  often  is,  merely  a  disjointed  torrent 
of  words. 

In  the  early  stage  of  mania,  incoherence  may  not  be  present, 
and,  even  when  beginning,  may  be  more  apparent  than  real, 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      89 

and  it  may  be  possible  in  large  measure  to  follow  the  utter- 
ances of  the  patient  throughout.  Further,  in  cases  that  are 
relatively  mild,  incoherence  may  never  occur.  It  does  not, 
therefore,  form  a  necessary  symptom  of  mania.  However, 
in  typically  acute  cases,  it  is  not  only  established  but  becomes 
marked  as  the  affection  progresses. 

Delusions  as  such  play  no  role  in  mania,  a  fact  which  the 
previous  discussion  might  well  have  led  us  to  anticipate.  De- 
lusions presuppose  reflection,  some  degree  of  introspection 
and  analysis,  but  nothing  of  this  kind  occurs  in  mania;  the 
entire  attitude  is  emissive,  objective.  However,  the  patient 
seems  to  have  an  expanded  sense  of  well-being;  he  may  mani- 
fest excessive  notions  as  regards  his  strength  and  powers  gen- 
erally. He  is  boastful,  ambitious,  erotic.  Transient  ideas  of 
greatness,  importance,  or  consequence  constantly  manifest 
themselves,  but  they  are  not  evolved  into  well-formed  delusions. 
Least  of  all  are  they  systematized  or  fixed;  they  shift  with  the 
constantly  changing  and  illusory  perceptions  and  manifold 
associations. 

Hallucinations,  also,  form  no  part  of  the  clinical  picture  of 
mania.  They  do  occur,  but  their  occurrence  is  only  occa- 
sionally noted.  The  patient  is  so  taken  up  with  that  which 
is  going  on  about  him  that  he  either  does  not  observe  or 
pays  no  attention  to  hallucinations  if  present;  only  now  and 
then,  during  a  relatively  quiet  period,  does  he  react  in  a  way 
which  justifies  us  in  assuming  their  existence.  Suffice  it  to  say, 
however,  that  in  by  far  the  larger  number  of  cases  they  are 
clearly  not  present. 

Sleep,  as  might  be  expected,  is  greatly  disturbed.  Usually 
it  is  for  a  time  abolished  altogether;  insomnia  is  stubborn  and 
resistant,  and  persists  more  or  less  during  the  active  period  of 
the  attack. 


90  MENTAL    DISEASES 

Cases  of  acute  mania  differ  of  course  considerablj''  from  each 
other.  One  case  may  be  relatively  mild,  the  symptoms  sug- 
gesting perhaps,  in  the  degree  of  their  intensity,  an  alcoholic 
intoxication.  In  others  the  excitement  may  reach  a  very  high 
degree.  The  patient  who  early  in  the  attack  is  good  natured, 
pleased,  and  in  a  measure  tractable,  may  later  become  exceed- 
ingly violent,  may  tear  his  clothing,  and  may  strip  himself  nude. 
He  may  become  combative;  the  slightest  cause  may  provoke 
explosions,  during  which  he  curses  and  shouts,  gives  vent  to 
threats,  abuse,  and  vituperation;  his  language  is  profane, 
filthy,  and  obscene.  Sometimes  he  becomes  wildly  destructive, 
and  attempts  frantic  attacks  on  those  about  him.  Happily 
outbreaks  of  such  severity  are  infrequent;  nevertheless  they 
occur  and  are,  it  would  seem,  somewhat  more  common  among 
women  than  among  men. 

At  the  best,  the  manic  patient  is  untidy  and  dishevelled. 
Sometimes  he  wears  his  clothing  in  some  grotesque  fashion; 
at  others,  as  just  stated,  he  may  remove  it  altogether.  Every- 
thing denotes  a  loss  of  inhibition;  quite  frequently  the  patient 
is  erotic,  indulges  in  indecent  acts  and  gestures,  exposes  the 
person,  and  uses  obscene  words  and  expressions.  Masturbation 
too  may  be  practised.  He  may  also  become  filthy  from  his 
indifference  or  inattention  to  his  necessities.  He  may  urinate 
or  defecate  upon  the  floor.  Sometimes  he  smears  the  dejecta 
upon  the  walls  of  his  room,  sometimes  upon  his  person,  some- 
times he  rubs  them  into  his  hair,  his  mouth,  his  ears. 

The  physical  signs  may  be  enumerated  briefly.  The  rest- 
lessness may  be  accompanied  by  an  exaggeration  of  the  muscular 
strength;  it  seems,  especially  at  times,  to  be  actually  increased. 
The  patients  often  give  vent  to  muscular  efforts,  exceedingly 
violent  and  prolonged.  The  tendon  reflexes  are  not  especially 
altered.     The  cutaneous  sensibility  appears  to  be  diminished; 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      91 

especially  is  this  the  case  with  regard  to  impressions  ordinarily 
painful;  contusions,  bruises,  cuts,  and  even  more  serious  in- 
juries receive  little  or  no  attention  from  the  patient;  this  is 
also  true  of  heat  and  cold.  Doubtless  this  indifference  is  again 
to  be  ascribed  to  the  emissive,  the  "extraneous"  mental  attitude. 

The  special  senses  appear  to  be  more  acute  than  normally; 
perhaps  it  would  be  more  correct  to  say  that  the  patient  reacts 
inordinately  to  visual  and  auditory  impressions.  It  is  quite 
evident,  as  has  already  been  pointed  out,  that  he  does  not  per- 
ceive clearly  and  accurately,  does  not  interpret  his  impressions 
correctly. 

Digestion  is  at  first  impaired;  the  tongue  is  coated  and  there 
is  constipation.  Later,  the  tongue  becomes  clean,  at  times 
even  red  and  glazed;  constipation  disappears.  The  appetite, 
which  is  diminished  or  abolished  in  melancholia,  is  exaggerated 
in  mania,  sometimes  excessively  so,  the  patient  eating  glut- 
tonously. 

The  pulse  is  somewhat  rapid,  usually  more  so  in  periods 
of  increased  excitement.  As  the  attack  progresses  it  usually 
becomes  somewhat  slow  and  often  small.  The  force  of  the 
cardiac  impulse  is  usually  increased,  but  the  vascular  tension 
appears  to  be  diminished.  The  temperature  is  usually  normal ; 
rarely  it  is  slightly  subnormal.  A  rise  of  temperature  always 
indicates  a  visceral  complication. 

The  secretions  are  but  slightly  changed.  However,  the 
saliva  may  be  increased  in  amount;  many  patients  are  con- 
tinually spitting.  The  perspiration  is  also  in  some  cases  in- 
creased; sometimes  it  has  a  distinctly  greasy  and  sticky  feel, 
and  is  said  to  suggest  the  odor  of  mice.  At  other  times,  the 
skin  is  dry,  though  this  is  the  exception.  The  urine  Ukewise 
is  increased  in  quantity,  but  the  chemical  examination  reveals 
no  changes  of  moment;  possibly  a  diminution  of  the  phosphates. 


92  MENTAL    DISEASES 

In  women  irregularity  or  suppression  of  menstruation  is  the 
rule.  If  the  menses  appear,  there  is  apt  to  be  an  exacerbation 
of  the  excitement. 

That  there  is  loss  of  weight  in  the  course  of  an  attack,  to- 
gether with  marked  exhaustion,  especially  in  severe  cases, 
need  hardly  be  pointed  out. 

An  important  fact  remains  to  be  noted;  namely,  memory 
in  mania  may  be  better  than  in  health;  i.  e.,  it  may  be  exag- 
gerated. The  patient  is  often,  in  a  large  measure,  cognizant 
of  his  surroundings  throughout;  he  may,  therefore,  remember 
subsequently  the  detailed  events  of  his  illness  to  a  surprising 
degree;  a  true  hypermnesia  may  exist.  Marked  impairment  of 
memory,  it  should  be  added,  only  occurs  when  the  mania  has 
become  complicated  by  the  confusion  of  exhaustion — itself  un- 
usual— and  is  then  clouded  only  for  the  period  during  which  this 
confusion  existed. 

After  the  maximum  period  of  sjonptoms  has  lasted  for  some 
time — e.  g.,  two,  three,  four,  or  more  months — the  symptoms 
may  begin  to  decline.  The  excitement  gradually  subsides, 
the  sleep  improves,  the  patient  gains  in  weight,  and  little  by 
little  again  becomes  normal.  Sometimes  the  convalescence 
is  irregular  and  interrupted,  at  other  times  the  return  to  the 
lucid  state  is  sudden  and  abrupt.  As  in  melancholia,  the 
course  of  an  attack  of  mania  is  not  always  uniform,  but  is 
sometimes  intermittent. 

The  duration  of  an  attack  of  mania  is,  in  a  first  attack,  about 
two,  three,  or  four  months,  though,  as  in  melancholia,  it  may 
be  much  longer.  Other  things  equal,  it  is  shorter  the  more 
severe  the  attack.  On  the  whole,  the  rule  obtains  that  a  manic 
attack  is  shorter  than  one  of  melancholia. 

Diagnosis. — The  diagnosis  of  mania  offers  no  special  diffi- 
culties.    The  character  of  the  attack,  the  absence  of  hallucina- 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      93 

tions  and  delusions,  and  the  relatively  high  degree  of  lucidity 
serve  to  differentiate  it  from  delirium.  The  milder  cases  can 
with  equal  ease  be  differentiated  from  the  expansive  form  of 
paresis,  by  the  absence  of  the  physical  signs  so  characteristic 
of  the  latter  affection. 

Prognosis. — The  prognosis  is,  as  in  melancholia,  favorable 
as  regards  the  individual  attack,  in  the  majority  of  cases. 
Death  from  exhaustion,  accident,  or  visceral  complications 
may,  however,  occur.  Like  its  congener,  mania  is  an  affection 
which  is  essentially  recurrent.  The  intervals  between  attacks 
sometimes  extend  over  a  few  months,  more  frequently  over 
several  years.  Sometimes  the  attacks  are  few  and  far  between, 
as  in  a  patient  of  the  writer,  in  whom  two  attacks  were  ob- 
served with  an  interval  of  ten  years.  Such  long  intervals  are, 
however,  distinctly  the  exception.  For  a  further  consideration 
of  this  subject,  the  reader  is  referred  to  the  paragraphs  on  the 
prognosis  of  manic-depressive  insanity  at  the  close  of  the 
present  chapter. 

Hypomania 

Like  melancholia,  mania  does  not  always  present  itself  in 
the  form  here  pictured,  but  may  occur  in  a  subacute  form,  a 
form  termed  hypomania.  Occasionally  mania  does  not  rise  to 
a  higher  level  than  a  persistent  ''manic"  excitement;  that  is, 
the  disturbance,  while  possessing  the  essential  features  of 
mania,  never  equals  in  intensity  the  acute  form.  In  its 
way,  it  is  the  opposite  of  the  subacute  form  of  melancholia, 
hypomelancholia. 

Hypomania  forms  a  well-marked  clinical  entity;  however, 
there  are  transitional  forms  between  it  and  mania  proper; 
sometimes  it  is  a  prelude  to  the  latter.  Very  often,  too,  it  is 
clearly  but  a  phase  of  circular  insanity,  and  there  can  be  no 
doubt  as  to  the  position  which  it  should  occupy  in  our  nosology. 


94  MENTAL    DISEASES 

Symptoms  and  Course. — The  onset  of  an  attack  of  hypo- 
mania  is  probably  always  preceded  by  a  depressive  phase  in 
which  elements  of  a  melancholia  are  more  or  less  discernible. 
The  expansive  mental  state  is  gradually  established.  The 
same  emotional  and  intellectual  exaltation,  the  same  or  similar 
vagaries  in  conduct  may  be  early  observed  until  the  manic 
state  becomes  marked.  The  excitement,  however,  is  relatively 
limited,  the  altitude  of  the  wave  is  decidedly  lower  than  in 
mania  proper.  There  is  the  same  objective  and  emissive  atti- 
tude of  mind;  there  is  the  same  restlessness.  Association, 
as  before,  is  abnormally  increased,  and  is  usually  odd  and 
striking;  though,  owing  to  the  lessened  degree  of  excitement, 
this  symptom  is  not  so  pronounced.  It  may,  however,  give 
an  appearance  of  originality  and  brilliancy  to  the  patient's 
speech;  he  may  seem  witty  or  humorous,  or,  it  may  be,  im- 
pudent or  ironical. 

In  spite  of  the  general  mental  exaltation,  the  thoughts  may 
follow  each  other  in  orderly  sequence,  but  they  do  so  with 
abnormal  rapidity;  occasionally  the  patient  passes  abruptly 
from  one  theme  to  another.  He  expresses  himself  with  ease, 
replies  quickly,  and  may  indulge  in  repartee.  His  memory  is 
active,  he  recalls  events  readily.  However,  if  he  is  questioned 
much,  he  loses  patience,  does  not  answer,  becomes  involved, 
and  perhaps  a  little  incoherent.  Occasionally,  too,  gaps  occur 
in  which  sentences  are  broken;  speech  cannot  keep  pace  with 
the  speed  with  which  the  ideas  flow,  and  a  condition  then  re- 
sults which  reminds  us  of  mania  proper,  but  is  far  less  marked. 
The  abnormal  psychic  activity  is  also  shown  in  other  ways. 
The  patient  engages  in  or  proposes  various  ambitious  projects, 
business  enterprises,  inventions,  or  scientific  or  literary  under- 
takings out  of  all  proportion  to  his  resources;  he  shows  no 
appreciation  of  the  obstacles  in  his  path.     It  does  not  neces- 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      95 

sarily  follow  that  his  schemes,  his  inventions,  his  poems,  are 
devoid  of  value.  Usually,  however,  they  reveal  grave  defects 
of  judgment. 

The  patient's  feelings  and  moral  sense,  as  already  stated, 
are  less  acute.  He  is  apt  to  neglect  his  family,  he  no  longer 
manifests  for  them  the  same  affection  as  formerly;  often  he 
reserves  his  ill  humor  and  fits  of  anger  for  the  home  circle. 
To  strangers  he  may  appear  as  a  person  of  agreeable  manners 
until  he  offends  by  his  egotism,  fatigues  by  his  loquacity,  alien- 
ates by  his  ill-considered  conduct.  His  moral  sense,  too,  is 
suspended;  he  may  give  free  play  to  his  sexual  instincts,  may 
lose  all  reserve,  may  drink  to  excess,  may  commit  acts  openly 
which  compromise  his  reputation.  Women,  also,  frequently 
betray  marked  sexual  excitement.  Their  eroticism  may  reveal 
itself  in  wearing  striking  apparel,  in  audacious  advances,  in 
open  solicitation,  in  making  violent  love  to  any  man  who  hap- 
pens to  be  near,  irrespective  of  his  age,  fitness,  or  social  position. 
Sometimes  engagements  to  marry  are  entered  into;  sometimes, 
too,  the  unfortunate  patient  becomes  pregnant. 

In  hypomania,  as  in  mania  proper,  the  memory  may  be  much 
exalted;  in  many  cases  remarkable  hypermnesia  is  present. 
The  patient  recalls  historical  events  and  dates  and  other  mat- 
ters with  great  accuracy  or  quotes  word  for  word  from  books — 
sometimes  whole  pages — which  he  has  not  read  for  many  years, 
and  of  which,  in  his  normal  condition,  he  can  usually  recall 
little  or  nothing.  The  patient  may  also  observe  his  surround- 
ings with  abnormal  minuteness,  and  may  subsequently  give  a 
remarkably  detailed  and  accurate  account  of  all  that  occurred 
during  his  illness.  One  of  my  patients  dictated  to  a  stenog- 
rapher the  detailed  daily  events  occurring  shortly  preceding  his 
illness,  including  his  arrest  and  subsequent  commitment,  and 
covering  the  entire  period  of  his  stay  at  the  asylum,  extending 


96  MENTAL    DISEASES 

over  many  months  of  time.  As  happens  not  infrequently,  in 
cases  of  hypomania,  the  patient  claimed  that  he  had  been  im- 
properly committed.  He  entered  suit  against  his  physicians, 
and,  among  other  things,  maintained  that  the  fact  that  he 
remembered  ever^^thing  pertaining  to  his  alleged  insanity,  in 
such  minute  detail,  was  prima  facie  e\ddence  that  he  had  been 
sane  throughout.  It  need  hardly  be  added  that,  abandoned 
early  by  his  attorney,  his  suit  came  to  naught.  In  another 
instance  of  hypomania,  a  woman  who  was  in  a  condition  of  ex- 
treme eroticism,  and  had  cormnitted  flaring  acts  of  solicitation, 
was  as  a  last  resort  committed  to  an  asylum.  She  communicated 
by  letter  with  the  mayor  of  the  city  and  with  a  prominent 
attorney,  alleging  that  she  was  being  illegally  restrained  of  her 
liberty.  Her  case  was  promptly  taken  up,  but  after  a  time 
both  mayor  and  attorney  were  convinced  that  she  was  insane. 
Meanwhile,  both  friends  and  physicians  were  subjected  to 
considerable  annoyance;  she  was,  not'withstanding,  held  at 
the  asylum  until  the  manic  wave  had  subsided,  and  publicity 
— and  what  was  to  the  relatives  scandal  and  disgrace — was 
avoided. 

It  is  a  remarkable  fact  that  sexual  elements  play  an  especially 
prominent  part  when  the  hj-pomanic  wave  occurs  as  the  middle 
period  of  life  is  approached;  e.  g.,  in  the  early  forties.  The 
recrudescence  of  sexual  feeling  may  be  very  marked  and  may 
constitute  the  most  striking  s\Tnptom  of  the  case,  the  general 
manic  features  being  relativeh*  less  prominent.  For  instance,  a 
woman  who  has  been  absoluteh'  chaste  both  in  thought  and  con- 
duct and  apparently  happily  married  for  j-ears,  complains  to  her 
physician  that  her  husband  is  not  as  attentive  as  formerly, 
that  he  does  not  satisfy  her  sexually,  that  he  is  indifferent  or 
incompetent,  while  she  herself  is  perfectly  healthy  and  in  various 
waj's  intimates  or  broadly  states  that  both  her  desires  and  her 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      97 

capacities  are  very  great.  It  is  but  a  step  farther  for  such  a 
woman  to  fall  in  love.  Not  infrequently  it  is  with  some  one 
much  younger  than  herself;  intrigues,  gross  breaches  of  conduct, 
scandal  and  elopement  may  follow.  At  times  the  patient  falls 
in  love  with  some  one  whom  she  has  greatly  admired,  it  may 
be  her  minister,  physician  or  other  person  whom  she  has  fre- 
quently met.  In  such  case,  her  advances,  often  open  and  un- 
concealed, sometimes  accompanied  by  frank  avowals,  cause  no 
small  embarrassment  to  the  persons  concerned.  Sometimes 
the  patient,  in  order,  it  would  seem,  to  satisfy  her  scruples  and 
to  be  in  keeping  with  her  previous  life,  may  give  to  the  affection 
a  platonic  coloring. 

I  know  of  no  cases  more  difficult  of  management  than  cases 
of  hypomania.  Advice  and  admonition  are  alike  rejected; 
attempts  at  control  are  resented  as  unwarranted  interference 
by  both  men  and  women.  Sometimes  vague  ideas  of  persecution 
make  their  appearance  and  may  lead  to  acts  of  violence.  When 
commitment  to  an  asylum  is  finally  the  only  way  out,  lawyers 
and  physicians  are  alike  appealed  to  by  the  patient,  and  so  great 
is  the  apparent  lucidity  that  attorneys  will  always  be  found — 
and  for  that  matter,  unfortunately,  physicians  also — who  will 
take  up  the  supposed  cause  of  the  patient.  That  under  these 
circumstances  great  harm  may  ensue  to  the  patient  and  to  his 
best  interests  may  well  be  imagined. 

In  hypomania,  as  in  ordinary  mania,  the  clothing  of  the 
patient  may  be  disarranged  or  dishevelled.  Especially  is  this 
apt  to  be  the  case  if  the  excitement  is  pronounced,  approxi- 
mates that  of  mania  proper,  or  is  of  long  duration.  Sometimes 
in  such  instances  the  patient  may  put  on  his  clothing  in  a 
grotesque  manner,  turn  his  coat  inside  out,  thrust  his  trousers 
into  his  stockings,  tear  off  his  buttons,  and,  very  curiously, 
may  make  finger-rings  or  bracelets  out  of  pieces  of  string  or 

7 


98  MENTAL    DISEASES 

yarn.  Often,  too,  he  collects  and  puts  into  his  pockets  the 
most  miscellaneous  objects,  such  as  fragments  of  bread,  stumps 
of  cigars,  dried  leaves,  strings,  pieces  of  paper,  fragments  of 
rags,  pieces  of  glass,  or  nails.  Sometimes  he  scatters  or  ar- 
ranges such  objects  about  his  room,  or  stuffs  hair,  rags,  or  dirt 
into  his  nose  or  ears. 

Physical  signs  are  absent  in  hypomania  as  in  mania 
proper.  Sometimes  there  is  a  slight  tremor  of  the  hands; 
at  other  times,  due  to  the  hurried  speech,  the  patient  betrays 
a  faulty  enunciation;  never,  however,  the  atactic  speech  of 
paresis. 

Neither  the  digestive  tract  nor  the  circulatory  apparatus 
reveal  special  symptoms.  The  appetite  is  good,  but  the  weight 
is  usually  below  normal. 

The  course  is  like  that  of  ordinary  mania,  in  so  far  as  it  is 
wave-like,  though  the  altitude  of  the  wave,  as  already  stated, 
is  much  lower.  Again,  the  duration  of  an  attack  of  hypomania 
is  much  longer;  eight  months,  a  year,  a  year  and  a  half,  two 
years,  or  more.  The  subsidence  is  usually  gradual.  In  some 
cases  it  would  seem  that  the  condition  never  entirely  disappears; 
such  individuals,  it  would  seem,  are  somewhat  "manic"  all  of 
their  lives.  (See  Part  II,  Chapter  III.)  However,  in  the 
majority  of  cases  the  patient  becomes  normal  for  a  time, 
but  only  to  suffer  later — perhaps  soon,  perhaps  after  months 
or  years — from  another  attack,  or  perhaps  from  an  attack  of 
melancholia. 

Diagnosis.—  The  diagnosis  is,  as  a  rule,  made  without  diffi- 
culty. The  expansion,  the  emissive  and  objective  attitude, 
the  anomalies  of  association,  the  absence  of  hallucinations  and 
delusions,  and  the  relatively  high  degree  of  lucidity  leave  no 
room  for  doubt.  A  differentiation  from  paresis  is  made  by  the 
absence  of  physical  signs  and  from  the  expansive  stage  of  para- 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY      99 

noia  by  the  absence  of  the  systematized  delusions  and  other 
cognate  sjrmptoms  unnecessary  to  detail  here.  A  serological 
examination  is  usually  unnecessary;  though  in  cases  at  all 
doubtful,  it  should  be  made  and  should  include  both  the  blood 
and  the  cerebrospinal  fluid.    (See  section  on  Paresis.) 

Prognosis. — The  prognosis  as  regards  the  outcome  of  the 
individual  attack  is,  on  the  whole,  favorable,  though  less  so 
than  in  the  acute  form. 

CIRCULAR    INSANITY 

Circular  insanity,  periodic  insanity,  insanity  of  double  form, 
is  characterized  by  an  alternate  succession  of  attacks  of  mel- 
ancholia and  mania. 

Two  widely  different  phases  present  themselves,  into  the 
detailed  consideration  of  which  it  is  unnecessary  to  enter  again. 
As  may  be  inferred  from  the  sections  on  melancholia  and 
mania,  the  transition  from  one  phase  to  the  other  may  be 
direct;  i.  e.,  without  any  appreciable  interval,  or  there  may  be 
an  interval  during  which  the  patient  is  normal  or  relatively  so. 
The  direct  transition  is  perhaps  more  frequently  observed.  If 
there  be  an  interval,  this  is  usually  of  uncertain  length.  The 
two  phases  form  a  cycle.  Further,  they  may  alternate  with 
each  other  in  various  ways;  thus,  an  acute  attack  of  melan- 
cholia may  be  followed  by  an  acute  attack  of  mania,  the  dura- 
tion of  the  first  phase  being,  we  will  say,  four  months,  that  of 
the  second  three;  the  waves  being  of  equal  altitude,  the  mel- 
ancholic wave  is  somewhat  longer  than  the  manic.  Again,  a 
hypomelancholia  may  alternate  with  a  hypomania.  However, 
almost  every  order  of  succession  has  been  observed;  e.  g.,  a 
hypomelancholia  may  precede  an  acute  attack  of  mania,  per- 
haps intense  in  degree,  or  an  acute  attack  of  melancholia  may 
be  followed  by  a  mild  and  prolonged  wave  of  hypomania.     In 


100  MENTAL    DISEASES 

other  words,  there  may  be  no  correspondence  whatever  in  the 
altitude  or  duration  of  the  opposite  phases. 

As  already  stated,  the  two  phases  constitute  a  cycle.  Very 
rarely,  it  is  said,  such  a  cycle  may  occur  only  once  in  the 
lifetime  of  an  individual.  However,  the  truth  doubtless  is 
that  such  an  observation  is  merely  incomplete  and  takes  no 
note  of  mild  melancholic  and  manic  waves  that  have  occurred 
previous  to  or  since  the  frank  attack. 

A  cycle  may  embrace  a  number  of  months,  a  year,  a  year 
and  a  half,  or  longer.  It  may  at  once  be  followed  by  another 
cycle,  and  this  by  a  third,  and  so  on.  In  other  words,  the  pa- 
tient may  suffer  from  a  continuous  circular  insanity.  Again, 
and  this  is  the  more  frequent  as  it  is  also  the  less  distressing 
form,  the  various  cycles  are  separated  from  each  other  by  a 
period  during  which  the  patient  is  normal  or  relatively  so. 
This  period  may  be  short,  but  not  infrequently  it  is  prolonged 
and  extends  over  several  years.  Further,  the  successive  cycles 
may  bear  a  general  resemblance  to  each  other,  both  as  to  se- 
verity and  duration;  sometimes,  indeed,  they  are  very  much 
alike;  less  frequently  they  vary  decidedly.  When  the  suc- 
ceeding phases  are  short — when  the  cycle  itself  is  short — the  in- 
terval is  apt  to  be  lacking.  It  should  be  added,  also,  that  the 
manic  phase  may  be  the  first  in  the  series;  /.  e.,  the  first  to  which 
attention  is  given.  There  is  reason,  however,  to  believe,  as  al" 
ready  shown,  that  it  is  always  preceded  by  a  depressive  phase. 

Finally,  cases  present  themselves,  though  infrequently,  in 
which  depression  and  expansion  alternate  at  verj-^  brief  intervals; 
for  example,  on  succeeding  days,  or  ,  it  may  be,  change  between 
night  and  morning;  or  in  which  elements  of  depression  and  ex- 
pansion are  present  during  various  periods  of  the  same  d2iy. 


GROUP   II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY     101 

Such  cases  have  been  described  as  the  "mixed"  form  and  are  in 
the  larger  number  of  instances  to  be  observed  during  the  period 
of  transition  from  one  phase  to  another;  for  instance,  during  the 
subsidence  of  a  melancholia  and  the,  as  yet,  incompletely  es- 
tablished phase  of  a  mania. 

THE    PROGNOSIS    OF    MANIC-DEPRESSIVE    INSANITY    IN 

GENERAL 

General  Conclusions. — The  following  facts,  already  pointed 
out,  may  be  considered  as  established:  First,  the  prognosis 
of  an  individual  attack  of  melancholia  or  of  mania  is  good; 
i.  e.,  the  patient,  other  things  equal,  is  likely  to  recover  from  the 
attack.  Especially  is  this  true  of  the  attacks  that  occur  in 
early  life.  As  regards  the  melancholic  phase,  we  have  among 
the  most  favorable  indications  the  typical  and  acute  character 
of  the  attack,  the  absence  of  stupor,  and  the  absence  of  marked 
disturbances  of  nutrition.  As  regards  the  manic  phase,  the 
outlook  is  again  more  favorable  in  proportion  to  the  frank 
character  of  the  attack  and  the  moderate  degree  of  the  ex- 
haustion. 

The  subject,  however,  presents  itself  in  another  and  far  more 
serious  aspect.  Clinical  experience  has  shown  that  the  attacks 
of  both  melancholia  and  mania  recur.  Isolated  attacks  are 
excessively  rare.  Second,  phases  of  melanchoHa  may  be 
succeeded  by  phases  of  mania  and  vice  versa.  Third,  while 
manic-depressive  insanity  is,  to  all  intents  and  purposes,  one 
affection,  one  in  which  both  the  melancholic  and  the  manic 
phases  occur,  these  two  phases  do  not,  by  any  means,  occur 
with  equal  frequency.  Thus,  it  is  undoubtedly  a  fact  that  typ- 
ical acute  mania  occurs  much  less  frequently  than  typical 
acute  melanchoHa.  Further,  an  increasing  experience  shows 
that,  in  cases  which  appear  at  first  sight  to  be  merely  recurring 


102  MENTAL    DISEASES 

attacks  of  melancholia  with  normal  periods  intervening,  these 
intervals  are  verj^  frequently  periods  of  mild  manic  elation; 
not^\ithstanding,  they  do  not  constitute  well-developed  attacks 
of  mania,  perhaps  are  at  most  an  approach  to  hypomania. 
Finally,  cases  of  melancholia  are  time  and  again  met  with  in 
which  the  patient  must  be  regarded  as  entirely  normal  in  the 
intervals,  intervals  which  sometimes  extend  over  many  months 
and  years.  The  fact  remains,  let  us  repeat,  that  acute  mania 
occurs  much  less  frequently  than  acute  melancholia. 

Again,  as  regards  the  manic  attacks  themselves,  clinical 
experience  justifies  another  generalization;  namely,  that  they 
occur  more  frequently  and  with  greater  intensity  in  early  life 
than  later.  Acute  manias,  as  we  have  already  pointed  out, 
have  their  first  onset  most  frequently  in  the  third  decade  of 
life;  they  recur  subsequently,  but  they  recur  with  a  diminish- 
ing frequency  and  diminishing  intensity,  and  become  quite 
rare  as  the  middle  period  of  life  is  approached. 

As  regards  melancholia,  clinical  experience  appears  to  justify 
the  following  generaUzations :  First,  frequently,  in  the  attacks 
which  occur  early  in  life,  it  happens  that,  while  the  general 
symptoms,  psychic  suffering,  self-accusation,  tendency  to  sui- 
cide, are  present  in  great  force,  a  highly  evolved  special  delu- 
sion of  the  unpardonable  sin,  such  as  is  met  with  in  later  attacks, 
may  not  be  present.  The  detailed  picture  of  first  attacks  may 
differ  in  this  respect  from  second  or  third  attacks,  and  more 
particularly  from  the  melancholia  of  middle  life.  Second, 
somatic  delusions,  i  e.,  delusions  hj^^ochondriacal  in  tj^je,  are 
more  frequently  met  with  in  the  older  cases  than  in  the  younger, 
and  reach  their  typical  development  in  the  melancholia  of  mid- 
dle life.  Third,  a  review  of  the  clinical  findings  also  justifies  the 
inference  that  recurring  attacks  of  melancholia  tend  to  increase 
in  duration;  i.  e.,  each  successive  attack  is,  other  things  equal, 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY     103 

somewhat  longer  than  the  preceding  attacks.  While  there  are 
exceptions  to  this  rule,  it  is  in  the  main  correct.  Certain  it  is 
that  attacks  occurring  in  middle  life  are  much  more  prolonged 
than  attacks  occurring  in  early  life. 

Further,  it  has  been  with  the  writer  an  almost  unvarying 
experience  that  when  a  melancholia  occurs  in  middle  life — i.  e., 
is  said  to  have  begun  in  middle  life — a  careful  study  of  the 
personal  history  will  show  that  in  reality  the  attack  from  which 
the  patient  suffers  is  not  a  first  attack.  If  the  life  history  of 
the  individual  be  carefully  studied  from  early  youth  on,  it  will 
frequently  be  found  that  he  has  suffered  from  periods  of  de- 
pression previously;  not  pronounced,  perhaps,  but  nevertheless 
existent,  and  often  to  the  degree  of  attracting  the  attention  of 
members  of  the  family.  Not  infrequently  I  have  unearthed 
clear  histories  of  waves  of  depression  recurring  at  intervals 
and  of  many  months'  duration.  Sometimes  the  history  reveals 
instead,  and  in  a  most  surprising  way,  a  clear  history  of  re- 
peated periods  of  long  sustained  and  abnormal  activity,  em- 
bracing great  enterprises  and  projects,  each  period  brought  to 
an  end,  achievement  frustrated,  by  a  period  of  ill-health,  a 
''breakdoT\'ii."  Sometimes  the  history  of  recurring  phases  of 
manic  activity  brought  to  light  in  a  case  of  melancholia  of 
middle  life  is  most  striking.  In  one  of  my  patients  enormous 
business  success  ensued  during  these  periods,  with  lack  of 
progress  and  indifference  in  the  intervals.  Such  a  history  is 
most  suggestive,  and  clearly  proves  that  the  middle-age  melan- 
cholia, which  is  perhaps  the  first  attack  which  leads  the  family 
physician  to  call  in  a  specialist,  is  by  no  means  the  first  attack 
of  the  affection  from  which  the  patient  has  suffered.  The  early 
fife  of  my  patient  was  clearly  featured  by  hypomanic  states, 
interlarded  perhaps  with  states  of  depression  relatively  insig- 
nificant.    The  writer  believes  that  the  more  the  phases  of 


104  MENTAL    DISEASES 

depression  or  of  expansion  occurring  in  a  life  history  are 
studied,  the  more  will  the  conclusion  be  justified  that,  whether 
occurring  early  or  late  in  life,  they  belong  to  one  and  the  same 
symptom  group,  and  that  violence  is  done  in  attempting  to  sepa- 
rate out  a  special  clinical  form  for  middle  life,  a  so-called  melan- 
choUa  of  involution.  Again,  a  manic  state  is  sometimes  found 
in  middle  life,  either  interlarded  between  phases  of  depression 
or  existing  perhaps  as  a  well-defined  hypomanic  wave;  as 
witness  the  hyperactivity,  excitement,  and  eroticism  some- 
times met  with  in  women  in  the  early  forties,  women  some  of 
whom  subsequently  develop  a  middle-age  melancholia.  Some- 
times, indeed,  this  manic  wave  burns  with  a  fierce  brilliancy; 
it  is  rare,  but  it  does  occur.  The  writer  once  had  under  his 
care  and  observation,  at  one  and  the  same  time,  two  sisters, 
one  of  whom,  aged  forty-six,  was  suffering  from  a  typical  long- 
drawn  melancholia  of  middle  life,  while  the  other,  two  years 
her  junior,  was  confined  in  a  neighboring  asylum  with  a 
typical  attack  of  mania.  Like  the  melancholia,  the  mania 
was  of  long  duration  and    unpromising. 

Manic-depressive  insanity  may  persist  during  the  lifetime 
of  the  patient;  rarely  the  attacks  cease  to  recur.  Sometimes 
they  come  to  an  end  with  one  or  two  prolonged  attacks  of  melan- 
cholia in  middle  life.  In  other  cases,  again,  the  attacks  con- 
continue  to  recur,  become  chronic,  or,  perhaps  in  the  form  of 
phases  of  hypomelancholia,  persist  into  old  age.  Occasionally 
it  is  just  in  old  age  that  profound  waves  of  melanchoUa  occur — 
profound  and  persistent — and  yet  even  here  recoveries  may 
ensue. 

Another  important  question  remains  to  be  considered. 
Clinical  experience  has  shown  that  patients  pass  through  manic 
and  depressive  attacks  without  suffering  any  mental  deteri- 
oration.    When  the  phase  has  subsided,  the  patient  presents 


GROUP   II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY     105 

no  evidence  of  loss  or  impairment  of  any  of  his  faculties.  This 
fact  is  one  of  the  most  striking  in  all  the  varied  phenomena 
presented  by  mental  disease.  When  recovery  ensues  it  is  com- 
plete. However,  like  many  another  general  truth,  it  is  not 
absolute;  there  are  a  certain  number,  a  very  small  number,  of 
exceptions.  First,  as  already  stated  in  regard  to  melancholia, 
the  attacks  tend  to  increase  in  duration,  both  with  recurrence 
and  with  increasing  age.  Second,  to  this  it  must  now  be 
added  that  the  prognosis  of  individual  attacks  becomes  less 
assured  as  middle  age  is  approached  and  least  so  when  middle 
age  is  reached;  that  is,  there  is  a  distinct  tendency  to  the  pro- 
longation of  the  attack  over  an  increasing  period  of  time. 
Again,  recovery  is  now  and  then  clearly  not  complete;  there  is 
a  distinct  and  persistent  residual  mental  impairment.  Finally, 
an  attack  of  melanchoha  occasionally  extends  over  three,  four, 
or  more  years;  if  so  it  is  to  be  fairly  regarded  as  chronic 
and  as  offering  but  little  hope  of  improvement;  the  writer 
has,  however,  seen  an  excellent  recovery  in  a  woman  suffering 
from  a  middle-age  melancholia  after  four  years.  At  times,  the 
mental  impairment  that  ensues  in  chronic  cases  amounts  to  a 
true  dementia,  a  so-called  secondary  or  terminal  dementia; 
sometimes  this  is  spoken  of,  though  improperly,  as  a  secondary 
paranoia.  There  may  be  a  persistence  of  depressive  delusions, 
sometimes  vague,  sometimes  clearly  outlined.  The  delusions 
may  become  more  or  less  fixed,  and  may  resemble  those  of  a 
paranoia.  They  may  consist  of  ideas  of  ill  treatment,  abuse, 
and  even  persecution.  Not  infrequently  they  are  accompanied 
by  visceral  and  other  hallucinations.  In  time  they  are  likely 
to  undergo  degeneration,  to  become  grotesque,  absurd,  hypo- 
chondriacal. The  appearance  of  a  paranoid  attitude  in  the 
course  of  a  melancholia  is  always,  it  should  be  emphasized, 
an  unfavorable  sign.    In  states  terminal  to  mania  an  analogous 


106  MENTAL    DISEASES 

picture  may  be  presented ;  there  may  be  an  indefinite  persistence 
of  symptoms  and  of  ambitious  or  expansive  ideas  poorly  ar- 
ranged, with  mental  impairment. 

In  former  years  the  diagnosis  of  chronic  melancholia  and 
chronic  mania  and  of  terminal  dementia,  the  outcome  of  these 
affections,  was  much  more  common  than  at  present,  but  this 
was  doubtless  owing,  in  many  instances,  to  the  failure  to 
properly  differentiate  melancholia  and  mania  from  the  excite- 
ments and  depressions  met  with  in  the  members  of  the  heboid- 
paranoid  group. 

In  regard  to  the  pathology  of  melancholia-mania  little  that 
is  definite  can  be  said.  The  mental  states  suggest  the  influence 
of  a  toxin — possibly  an  autotoxin.  However,  an  examination 
of  the  serum  of  the  blood  has  failed  to  reveal  the  presence  of  any 
defensive  ferments.  Such  ferments,  as  will  be  pointed  out  again, 
have  been  found  in  dementia  praecox,  both  against  the  sex 
glands  and  against  the  cortex;  but  in  manic-depressive  insanity 
neither  Fauser  nor  others  who  have  investigated  this  field 
have  ever  found  defensive  ferments  of  any  kind,  and  the  investi- 
gations have  included  the  sex  glands,  the  thyroid,  the  pituitary, 
pineal,  suprarenals,  muscle,  liver,  kidney,  cortex  and  other 
tissues.  It  would  seem  that  in  manic-depressive  insanity  a 
coarse  dysfunction  of  the  cortex  is  not  present,  but  rather  that 
there  is  an  excessive  or  an  insufficient  production  of  some  normal 
secretion,  against  which  a  defensive  ferment  is  not  formed. 
In  other  words,  in  manic-depressive  insanity  the  toxicity 
appears  to  be  due  to  a  quantitative  rather  than  to  a  qualitative 
change  in  substances  normally  present.  To  appreciate  the  sig- 
nificance of  this  fact,  we  must  bear  in  mind,  that  substances 
present  in  excess  or  abnormally  deficient  have  all  the  force  of 
poisons.  Of  this  truth  the  familiar  instances  of  hyper-  and 
hypothyroidism  offer  striking  examples. 


GROUP    II — MELANCHOLIA,    MANIA,    CIRCULAR    INSANITY    107 

In  any  event,  whatever  the  disturbing  cause,  it  must  be 
endogenous;  of  this  there  can  be  no  doubt,  for  manic-depressive 
insanity  bears  no  relation  to  infectious  processes  or  other  poison- 
ings of  extraneous  source.  It  has  sometimes  been  attempted 
to  refer  the  affection  to  gastro-intestinal  auto-intoxication,  but 
the  gastro-intestinal  atony  is  itseK  an  outcome  of  the  disease, 
a  symptom  of  defective  innervation;  treatment  directed  to  the 
digestive  tract  has  uniformly  failed  to  modify  the  progress 
of  the  sjrmptoms  in  the  shghtest  degree.  Finally,  theories  have 
also  been  formed  ascribing  a  psychogenic  origin  to  melancholia 
and  mania,  but  such  theories  are  clearly  inapplicable  in  an 
affection  which  is  essentially  hereditary  and  innately  neuropathic. 


CHAPTER  V 

GROUP  in.-THE   HEBOID-PARANOID   AFFECTIONS 

(Dementia  Praecox;  Paranoia) 

The  group  considered  in  the  present  chapter  consists,  as 
already  indicated  in  Chapter  II,  of  affections  essentially  de- 
generative in  their  nature.  It  would  seem  that  we  have  here 
to  deal  with  individuals  who  are  defective  in  their  organization, 
with  persons  who  have  had  transmitted  to  them  from  their 
ancestors  a  structure  so  imperfectly  or  so  aberrantly  constituted 
that  it  breaks  dovm  under  the  mere  strain  of  living.  The 
breakdown  may  occur  early  or  relatively  early,  and  it  then  pre- 
sents itself  in  the  form  of  an  insanity  of  youth,  a  so-called 
precocious  dementia;  or,  the  breakdown  may  not  occur  until 
adult  life  has  been  reached,  when  it  presents  itself  in  the  form 
of  a  delusional  insanity,  a  so-called  paranoia.  Inasmuch, 
therefore,  as  this  group  includes  both  juvenile  and  paranoid 
insanity,  I  have  for  some  years  applied  to  it  the  designation  of 
the  heboid-paranoid  group.  This  group,  as  we  will  see,  forms 
a  natural  whole,  though  composed  of  a  number  of  clinical 
forms.  The  term  heboid-paranoid  is  not  only  in  a  sense 
descriptive,  but  serves  to  distinguish  it  clearly  from  the  other 
groups. 

All  observers  are  agreed  as  to  the  large  proportion  of 
hereditary  factors.  These  are  variously  estimated  at  from 
52  per  cent,  by  Schott,  to  90  per  cent,  by  Zablocka.  The 
wide  variation  in  the  percentages  of  different  observers 
is  probably  due  to  differences  of  view  as  to  what  should  be 
included,  first,  in  the  general  term  of  hereditary  factors,  and, 
secondly,  as  to  what  affections  should  be  included  in  the  general 

108 


GROUP   III — THE    HEBOID-PARANOID    AFFECTIONS  109 

conception  of  dementia  prsecox.  Kraepelin  at  one  time  found 
hereditary  predisposition  to  mental  diseases  in  70  per  cent, 
of  his  cases,  though  he  thinks  that  this  may  possibly  have  been 
too  high.  He  states  that  when  the  inquiry  was  hmited  to  the 
direct  heredity,  i.  e.,  to  the  occurrence  of  mental  disease,  suicide, 
or  severe  brain  affections  in  the  parents,  it  yielded  33.7  per  cent., 
which  he  again  regards  as  too  low.  No  matter  how  we  approach 
the  subject,  however,  the  facts  justify  the  general  conclusion 
as  to  the  relative  frequency  of  neuropathic  family  histories  in 
dementia  prsecox.  In  such  family  histories,  we  should  note 
all  departures  from  the  normal;  not  only  crass  instances  of 
mental  disease,  but  also  the  occurrence  of  eccentric  or  unusual 
personalities,  criminals,  prostitutes,  tramps,  vagabonds,  misfits, 
and  failures  generally.  It  is  significant  in  this  connection  to 
note  the  varied  character  of  the  facts  presented  by  the  ancestry 
as  compared  with  the  relatively  limited  and  definite  character 
of  such  findings  in  manic-depressive  insanity. 

It  is  further  significant  that  every  now  and  then  dementia 
prsecox  occurs  in  a  number  of  individuals  in  the  same  family. 
Kraepelin  states  that  he  knows  a  large  number  of  such  instances. 
Personally  I  have  knowledge  of  one  family  in  which  no  fewer 
than  five  individuals  suffered  from  this  disease.  Dementia 
prsecox  is  only  infrequently  directly  transmitted  from  parent 
to  child,  as  the  great  mass  of  cases  develop  before  parenthood 
is  estabhshed.  This  statement  must,  of  course,  be  modified 
in  so  far  as  we  include  the  paranoid,  that  is,  the  older  cases — 
under  the  general  caption  of  dementia  prsecox.  Further,  not 
only  are  instances  of  dementia  prsecox  met  with  in  the  same 
family,  but  other  neuropathic  affections  as  well,  such  as  epilepsy 
and  hysteria,  and  at  times  also,  though  infrequently,  manic- 
depressive  insanity. 

Rudin,  from  studies  made  of  Kraepelin's  material,  comes  to 
the  conclusion  that  dementia  prsecox  is  probably  transmitted 


110  MENTAL    DISEASES 

in  accordance  with  the  Mendelian  law  and  appears  as  a  recessive 
quahty.  In  favor  of  this  view  he  regards  the  marked  predom- 
inance of  the  collateral  and  discontinuous  inheritance  over 
the  direct  inheritance,  the  increase  of  dementia  praecox  resulting 
from  inbreeding,  and  the  numerical  relation  of  those  attacked 
to  those  remaining  normal.  He  found  in  the  families  which  he 
studied  also  other  affections,  namel}-,  manic-depressive  insanity 
and  eccentric  personalities,  and  further  that  it  was  not  at  all 
infrequent  for  manic-depressive  parents  to  produce  children 
with  dementia  praecox,  while  the  reverse — namely,  manic- 
depressive  children  from  dementia  praecox  parents — belonged 
to  the  rare  exception.  Granting  the  possible  transmission  of 
dementia  praecox  in  accordance  with  the  Mendelian  law,  it  is 
also  evident  that  other  factors  which  directly  and  grossly  affect 
the  vitality  and  development  of  the  organism  variously  play  a 
role.  For  instance,  Riidin  noted  that  late  bom  or  last  born 
children  suffered  more  frequently  from  dementia  praecox 
than  others;  again,  that  immediately  preceding  or  following 
the  birth  of  a  praecox  patient  there  was  frequently  a  history  of 
miscarriage,  premature  birth,  or  stillbirth.  Of  equal  significance 
are  the  physical  and  psychic  stigmata  of  deviation  and  arrest 
that  are  found  in  individuals  who  acquire  dementia  praecox. 
Saiz  states  that  the  frequency  of  the  occurrence  of  the  physical 
stigmata  is  75  per  cent.  Among  the  latter  are  physical  feeble- 
ness, retardation  of  growth,  a  too  prolonged  juvenile  appearance, 
malformations  of  the  skull,  deep  and  narrow  palate,  persistence 
of  the  intermaxillary  bone,  abnormalities  of  the  ears,  fingers, 
or  toes,  imperfections  and  anomalies  of  the  teeth,  and  allied 
peculiarities. 

Facts  such  as  the  foregoing  indicate  that  in  given  instances 
the  germ  plasm  has  suffered  from  impairments  that  affect  its 
general  morphologic  and  biologic  properties  and  which  have 
profoundly  altered  and  lowered  its  possibilities  of  growth  and 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  111 

development.  Among  causes  which  may  thus  grossly  impair 
the  germ  plasm,  we  have  reason  to  believe,  are  infections  and 
intoxications  affecting  the  parent.  Pilcz,  Klutscheff,  and  others 
have  published  suggestive  statistics  as  to  the  frequency  of  syph- 
iUs  in  the  parents.  That  syphihs  may  play  a  role  is  extremely 
probable  on  other  grounds.  The  fact  that  the  Wassermann 
reaction  is  found  in  a  not  inconsiderable  proportion  of  dementia 
prsecox  cases,  e.  g.,  by  Bahr  in  32.1  per  cent.,  is  of  extreme 
significance.  Such  findings  do  not  mean  that  the  patients  are 
suffering  from  a  disease  of  the  nervous  system  due  to  inherited 
syphilis,  but  that  the  organism  as  a  whole  has  been  hampered, 
made  deviate  and  degenerate  in  its  development  by  the  presence 
of  the  spirochete  and  its  toxins;  i.  e.,  that  the  evolution  of  the 
organism  as  a  whole — and  included  in  this  the  development  of 
its  glands  of  internal  secretion — has  been  so  inhibited  and  altered 
that  at  a  given  point  in  its  life  the  organism  breaks  down  by 
reason  of  an  abnormal  and  toxic  metabolism.  The  clinical 
evidences  of  inherited  syphilis  are  absent  in  the  great  mass  of 
dementia  prsecox  cases,  and  it  is  not  necessary  that  the  Wasser- 
njann  or  other  tests  should  yield  a  positive  result;  it  is  sufficient 
that  the  infection  has  damaged  the  germ  plasm  of  the  parent. 

Again,  that  alcohol  likewise  damages  the  germ  plasm  hardly 
admits  of  doubt.  Diem,  Fuhrmann,  Riidin,  Wolfsohn,  and 
others  have  pubfished  studies,  alike  suggestive  and  significant, 
on  the  alcoholism  of  parents  in  dementia  prseeox.  Whether 
other  poisons  and  intoxications  play  a  role  in  bringing  about 
damage  to  the  germ  plasm,  we  are  obviously  unable  to  say, 
but  such  action  is  neither  impossible  nor  improbable.  In  any 
event,  however,  it  must  be  vastly  less  important  than  the  action 
of  syphilis  or  of  alcohol. 

It  seems  justifiable  to  assume,  first,  that  the  germ  plasm 
in  dementia  prsecox  may  be  laden  with  a  direct  tendency  to 
the  development  of  dementia  prsecox,  a  tendency  which  may 


112  MENTAL    DISEASES 

possibly,  as  Riidin  believes,  be  transmitted  as  a  recessive  quality 
in  conformity  with  Mendelian  principles;  secondly,  the  germ 
plasm  may  suffer  from  a  gross  impairment  the  result  of  syphilis, 
alcohol  or  more  rarely  of  other  infections  or  intoxications. 
The  first  cause  may  be  operative  without  the  second;  both  causes 
may  be  operative  together.  That  the  second  cause  may  be 
operative  alone  seems  extremely  probable.  Dementia  prsecox 
can  hardty  be  regarded  as  a  specific  clinical  entity  in  the  same 
sense  as  manic-depressive  insanity,  but  rather  as  a  group  of 
mental  affections  all  of  which  present  the  one  common  factor 
of  endogenous  deterioration. 

The  various  members  of  this  group  have  long  been  recog- 
nized. It  appears  that  the  insanities  occurring  in  the  juvenile 
period  were  kno\\Ti,  imperfectly  it  is  true,  to  Pinel,  to  Spurz- 
heim,  and  Esquirol.  Thus  the  latter  speaks  of  children  who 
are  very  well  at  birth,  who  increase  in  stature  at  the  same  time 
that  their  intelligence  develops,  and  who  are  very  sensitive, 
lively,  irritable,  passionate,  and  possessed  of  a  brilliant  imagi- 
nation, a  developed  intelligence,  and  an  active  spirit;  this 
activity  not  being  in  relation  to  the  physical  strength,  these 
creatures  use  themselves  up,  they  rapidly  exhaust  themselves, 
the  intelligence  becomes  stationary,  they  acquire  nothing  more, 
the  hopes  to  which  they  have  given  rise  vanish,  while  they 
finally  pass  into  a  terminal  period  of  dementia.  Surelj'  we 
have  here  a  picture  w'hich  strongly  suggests  the  modem  con- 
ception of  a  juvenile  dementia.  Morel,  in  his  treatise  on  mental 
diseases,  describes  cases  which  clearly  belong  to  the  simple 
form  of  the  juvenile  insanities,  and,  in  commenting  upon  them, 
he  says  that  an  immobilization  of  all  of  the  faculties,  une 
demence  precoce,  indicates  that  the  young  subjects  have  reached 
the  termination  of  the  intellectual  lives  of  which  they  are 
capable.  They  live  intellectually  only  up  to  a  certain  age, 
after  which  arrest  takes  place,  and  they  fall  progressively  into 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  113 

a  state  which  he  can  only  compare  to  idiocy.  Morel  was  the 
first  to  use  the  expression  precocious  dementia,  and  it  was 
Arnold  Pick,  who,  in  describing  cases  belonging  to  this  group, 
first  used  its  Latin  equivalent,  dementia  prsecox. 

Kahlbaum  early  differentiated  (1863,  1874)  two  forms,  which 
he  named  respectively  hebephrenia  and  catatonia,  and  later 
Hecker  (1877)  also  made  a  study  of  the  first  form,  hebephrenia. 
While  these  observers  were  succeeded  by  numerous  others,  it 
was  reserved  for  Kraepelin  to  recognize,  not  only  the  relation 
between  these  two  affections,  but  also  their  relation  to  the 
various  forms  of  paranoid  dementia.  He  thus  achieved  a 
brilliant  generaHzation,  one  that  has  served  to  greatly  reduce 
the  difficulty  of  study  and  classification. 

The  cases  of  the  heboid-paranoid  group  roughly  separate 
themselves  into  two  subgroups;  first,  the  juvenile  insanities, 
and,  second,  the  paranoid  dementias  of  the  adults.  This 
does  not  imply,  however,  that  these  two  subgroups  are  not 
closely  related.  It  is  to  dementia  prsecox  that  we  will  first 
give  our  attention. 

INSANITY  OF  ADOLESCENCE,  DEMENTIA  PRAECOX 

As  stated  above,  Kahlbaum  early  differentiated  two  forms, 
which  he  named  hebephrenia  and  catatonia.  Kraepelin,  while 
recognizing  the  distinction,  realized  that  it  was  not  possible  to 
separate  these  two  forms  sharply  from  one  another,  a  point  of 
view  which  is  now  universally  shared,  and  he  applied  the  term 
dementia  prsecox,  already  introduced  by  French  writers,  to 
both  conditions,  a  position  in  which  he  has  also  been  generally 
followed. 

Further,  there  can  be  no  doubt  that  hebephrenia  and  cata- 
tonia are  not  only  closely  related  symptom  groups,  but  that 
they  are  also  related  to  cases  in  which  the  sjnnptoms  resemble 


114  MENTAL    DISEASES 

or  suggest  those  of  a  delusional  lunacy;  i.  e.,  paranoia.  It  is 
wise,  therefore,  to  include  under  the  designation,  dementia 
praecox,  not  only  hebephrenia  and  catatonia,  but  also  a  para- 
noia-like juvenile  insanity,  a  paranoid  dementia.  Kraepelin 
is  disposed  to  include  under  the  last-mentioned  term  also  a 
large  group  of  adult  cases,  which  the  wTiter  believes,  in  common 
with  others,  had  best  be  classified  under  paranoia  itself. 
Having  disposed  of  these  preliminary  considerations,  let  us 
turn  our  attention  to  dementia  prsecox  in  general. 

The  onset  of  a  juvenile  insanity  may  take  place  at  any 
period  between  puberty  and  early  adult  life.  The  greater 
number  of  cases  occur  between  fourteen  and  twenty-five, 
perhaps  between  sixteen  and  twenty-three  years  of  age. 
However,  the  age,  as  may  well  be  imagined,  is  a  variable  factor; 
and  this  is  not  surprising  when  we  reflect  that  in  some  of  these 
patients,  due  to  a  delayed  development,  youth  occurs  late  and 
is  prolonged  into  what  would  otherwise  constitute  adult  life; 
in  others,  again,  puberty,  youth,  or  the  adult  period  all  come  on 
too  early.  The  question  of  age  will  again  be  touched  upon  in 
discussing  the  group  as  a  whole. 

Dementia  prsecox  is  said  to  be  somewhat  more  frequent  in 
males,  and  with  this  my  own  experience  appears  to  be  in  accord. 
The  fact,  if  true,  is  difficult  of  explanation. 

There  are  no  incidental  factors  of  etiology;  thus,  neither 
infections  nor  traumata  play  any  role. 

Symptoms  and  Course. — The  general  features  of  a  dementia 
praecox  may  be  outlined  as  follows :  first,  a  gradually  beginning 
onset  of  mental  symptoms,  usually  of  the  character  of  a  con- 
fusion, but  sometimes  possessing  elements  of  systematization ; 
second,  there  is  present  in  the  early  period  of  the  affection 
depression,  hypochondriasis,  exhaustion,  and  in  the  later  period 
expansion;  third,  in  the  great  majority  of  cases  the  affection 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  115 

is  progressive,  the  mental  impairment  steadily  increases  and 
terminates  in  dementia. 

It  is  usually  impossible  to  fix  the  time  when  the  affection 
begins,  so  slow  and  insidious  is  the  onset.  Frequently  the 
initial  symptoms  are  passed  by  or  no  attention  is  paid  to  them. 
Most  often,  however,  a  stage  can  be  recognized  in  which  the 
child,  or  rather  youth,  becomes  mentally  readily  fatigued; 
there  is  an  inability  to  do  mental  work;  there  is  headache, 
insomnia;  ideas  of  bodily  illness  make  their  appearance;  the 
child  feels  ill,  complains  of  being  ill,  is  clearly  hypochondriacal; 
restlessness,  irritability,  change  of  disposition  are  noted.  The 
child  is  unable  to  do  its  work  at  school  as  before;  is  unable  to 
take  in  new  ideas,  to  elaborate  or  properly  coordinate  them. 
Frequently  such  a  child  is  chided  for  being  lazy.  He  is  inat- 
tentive, indifferent,  lacks  interest,  is  depressed.  Sometimes 
he  plays  truant;  sometimes  he  runs  away  from  home. 

Soon  more  decided  mental  changes  are  noted.  It  is  ob- 
served that  the  patient  is  slow  and  heavy  mentally,  that  speech 
and  thought  are  alike  inhibited,  disconnected,  disordered. 
Sometimes  the  speech  is  suppressed  altogether  and  the  patient 
is  mute.  If  he  talks,  it  is  found  that  he  is  delusional;  his  de- 
lusions, however,  are  transient,  changing,  fragmentary,  feebly 
systematized,  or  not  systematized  at  all.  They  are  painful 
and  depressive  in  character  and  are  referred  to  causes  outside 
of  the  patient.  Sometimes  the  delusions  consist  merely  of 
ill-defined  notions  and  feelings;  at  other  times  they  are  very 
vivid  and  characterized  by  ideas  of  suffering,  torture,  poisoning, 
burning,  mutilation.  Quite  commonly  they  are  present  in  such 
number  as  to  dominate  the  picture,  and  they  indicate  more  or 
less  clearly  the  reference  by  the  patient  of  his  sufferings  to 
agencies  without;  i.  e.,  to  agencies  in  the  external  world.  In 
the  older  patients,  ideas  of  persecution  are  elaborated,  some- 
times vague,  sometimes  well  defined.     That  the  patient,  under 


116  MENTAL    DISEASES 

these  circumstances,  may  manifest  fright,  run  away,  or  may, 
on  the  other  hand,  strike,  commit  assault,  is  not  surprising. 
Sometimes,  though  rarely,  the  patient  evinces  ideas  of  crime, 
sin,  or  misdeeds,  but  they  are  an  indirect  outgrowth  of  his  ideas 
of  persecution.  At  most  they  are  fragmentary  and  ill-defined, 
and  we  never  see,  as  in  melancholia,  clearly  defined  self-accusa- 
tion, ideas  of  moral  unworthiness,  or  the  typical  delusion  of 
the  unpardonable  sin.  The  importance  of  this  distinction 
cannot  be  sufficiently  emphasized.  A  failure  to  recognize  it 
clearly  may  lead  at  times  to  errors  of  diagnosis. 

In  keeping  with  the  character  of  the  delusions,  hallucinations 
also  are  found  in  the  majority  of  cases.  Sometimes  they  are 
very  numerous.  Hallucinations  of  hearing  are  the  most  fre- 
quent, but  hallucinations  of  the  other  special  senses  and  of  the 
general  somatic  sense  may  also  be  present.  In  cases  that  pur- 
sue a  relatively  quiet  course  they  may  not  be  striking  or  promi- 
nent. Illusions,  also,  may  manifest  themselves,  though  they  do 
not,  as  a  rule,  play  a  very  important  role. 

The  depression  of  the  early  period  varies  greatly  in  dif- 
ferent cases  both  in  degree  and  in  the  character  of  the 
symptoms.  In  some  patients,  in  addition  to  the  other 
mental  features  already  considered,  it  may  be  characterized 
merely  by  an  absence  of  spontaneity,  by  apathy  and  emo- 
tional indifference;  usually,  however,  it  is  marked,  and  quite 
commonly  it  is  long  continued.  It  may  be  interspersed  by 
agitation,  and  the  patient  may  in  such  case  become  noisy 
and  much  disturbed.  Sometimes  the  depression  is  very  pro- 
found, and  it  may  gradually  deepen  until  the  patient  passes 
into  a  condition  of  stupor,  a  stupor  that  may  be  complete  and 
may  endure  for  many  weeks  or  months. 

The  mode  of  transition  from  the  depressive  to  the  expansive 
period  may  be  gradual,  and  indeed  this  appears  to  be  most  fre- 
quent.    The  depressive  ideas  become  less  prominent  and  ex- 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  117 

pansive  ideas  take  their  place;  or  it  may  be  that  during  an 
interval  depressive  and  expansive  ideas  are,  as  it  were,  com- 
mingled, first  one  group  and  then  the  other  being  more  promi- 
nent until  the  expansive  stage  is  finally  established.  Some- 
times the  transition  from  one  stage  to  the  other  is  rapid, 
sometimes  even  sudden  and  abrupt,  a  fact  which  we  will 
presently  consider  again. 

The  change  from  the  period  of  depression  to  the  period  of 
expansion  is  seen  most  typically  in  the  paranoid  cases;  i.  e., 
in  the  older  patients.  However,  both  depressive  and  expansive 
phases  are  presented  by  the  younger  patients,  the  cases  of 
hebephrenia  and  catatonia  as  well.  Hecker  long  ago  showed 
this  to  be  the  case  for  hebephrenia,  and  clinical  experience, 
it  may  be  safely  claimed,  shows  the  same  to  be  true  for  cata- 
tonia. The  slowly  oncoming  mental  change,  it  would  appear, 
is  accompanied  by  depression  to  which  expansion  sooner  or 
later  succeeds.  The  histories  of  cases  are,  it  must  be  admitted, 
often  unsatisfactory  as  regards  the  early  stage,  and  it,  therefore, 
happens  that  now  and  then  a  clearly  marked  depressive  phase 
seems  to  be  lacking.  I  am  quite  sure,  however,  that  this  is 
due  to  the  faulty  observation  or  absence  of  observation  by  rela- 
tives and  others  at  a  time  when  the  patient  is  still  without 
medical  care;  that  this  is  hkely  to  be  the  case  when  the  depres- 
sive period  is  relatively  mild  and  short  can  readily  be  imagined. 
Sometimes,  also,  attention  is  attracted  to  the  patient  in  the 
first  stage,  not  by  the  slowly  on-coming  symptoms  of  ill-health, 
but  by  some  sudden  or  striking  occurrence,  such  as  a  convul- 
sive seizure.  Indeed,  epileptiform  convulsions  are,  in  rare 
cases,  looked  upon  as  ushering  in  the  disease;  the  truth  doubt- 
less is  that,  just  as  in  paresis,  the  disease  has  pre-existed,  and 
that  the  onset  of  convulsions  has  served  merely  to  call  atten- 
tion to  its  existence.     Sometimes  the  convulsions  are  repeated; 


118 


MENTAL    DISEASES 


at  other  times  the  patient  suffers  from  fainting  spells,  sudden 
attacks  of  exhaustion,  or  even  from  rapidly  occurring  attacks 
of  stupor. 

Further,  the  oncoming  of  the  expansive  stage  may  be  long 
delayed,  and  indeed  nonexistent  during  the  time  that  the 
patient  is  under  medical  observation;  or,  it  may  be,  the  degree 
of  mental  impairment  having  become  pronounced,  the  phase 
of  expansion  may  be  evidenced  not  so  much  by  ideas  as  by 
conduct.  However  this  may  be,  it  may,  I  think,  be  safely 
claimed  that  the  generalization  as  to  the  initial  depression, 
subsequent  expansion,  and  general  mental  failure  holds  good, 
and,  as  we  will  see  later,  not  only  for  dementia  praecox  but 
for  all  of  the  members  of  the  heboid-paranoid  group. 

The  phases  of  depression  and  expansion  extend  over  a 
variable  period  of  time,  from  several  months  to  several  years. 
Finally,  the  disturbed  period  subsides,  and  the  patient  is  left 
with  a  mental  impairment  which  may  be  very  pronounced, 
moderate,  or  slight  in  degree;  indeed,  in  a  limited  number  of 
cases  it  may  be  so  little  marked,  or  even  absent  to  such  an 
extent  as  to  justify  the  opinion  that  the  patient  has  recovered. 
The  question  of  recovery  will  again  be  considered  later,  but  let 
us  emphasize  here  that  a  high  degree  of  recovery,  enduring  and 
persistent,  is  distinctly  the  exception.  Further,  and  this  is  the 
most  important  point  to  bear  in  mind,  that,  after  a  period  of 
improvement  has  in  a  given  case  ensued,  there  is  not  infre- 
quently, after  the  lapse  of  months,  sometimes  of  several  years, 
another  onset  of  a  delusional  and  excited  period,  after  which 
the  mental  impairment  becomes  more  evident;  indeed,  there 
may  be  several  such  recurrences  after  each  of  which  the  demen- 
tia becomes  more  pronounced.  Notwithstanding,  however, 
after  all  is  said  and  done,  we  must  not  forget  that  there  are 
cases  in  which  the  outcome  is  not  so  disastrous;    cases  which 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  119 

are  mild,  in  which  there  are  no  recurrences,  and  in  which  the 
final  result  must  be  looked  upon  as  a  recovery. 

The  delusions  of  the  expansive  period,  it  should  be  added, 
like  those  of  the  depressive  period,  are,  on  the  whole,  ill-defined, 
frequently  changing,  fragmentary,  and  not  at  all  or  poorly 
systematized.  They  may  in  various  degrees  be  accompanied 
by  excitement  and  exaltation,  and  may  betray  ideas  of  self- 
importance  or  consequence;  quite  commonly  they  have  an 
ambitious,  a  religious,  or  a  political  content.  Quite  commonly, 
too,  they  are  puerile  to  a  degree;  indeed,  it  may  be  said  with 
truth,  that  they  betray  an  intellectual  enfeeblement  somewhat 
more  advanced  than  that  of  the  depressive  period.  The  lan- 
guage is  in  keeping  with  the  mental  state.  It  is  exalted  and 
bizarre,  perhaps  turgid,  pompous,  or  declamatory.  Its  ex- 
pressions are  excessive;  it  is  filled  with  misplaced  phrases  that 
have  no  connection,  with  trivial  words,  or  with  words  or  sounds 
that  have  no  meaning. 

As  may  be  inferred  from  what  has  been  said,  various  anomahes 
of  association,  of  the  emotions  and  other  features  are  present; 
however,  clinical  simphcity  and  clearness  will  best  be  served  by 
deferring  the  psychologic  interpretation  of  the  symptoms  until 
a  later  portion  of  this  volume  is  reached.  (See  Part  III.) 
For  our  immediate  purposes,  the  mental  state  is  best  inter- 
preted as  a  confusion  which  in  some  cases— ^■.  e.,  in  the  older  or 
paranoid  forms — reveals  an  approach  to  systematization. 
There  are  present,  in  general  terms,  the  elements  of  a  confu- 
sional  insanity — i.  e.,  unsystematized,  fragmentary,  and  un- 
related delusive  ideas  together  with  hallucinations — a  symptom 
group  which  suggests,  to  say  the  least,  a  toxic  agency. 

This  confusional  insanity,  however,  because  of  the  period 
of  life  at  which  it  appears,  because  of  the  mode  of  onset,  and 
probably  because  of  the  nature  of  the  dementing  process  itself, 
presents  special  features.     Thus,  it  is  hardly  surprising  that 


120  MENTAL    DISEASES 

the  delusions  evolved  should  be  unsystematized  and  but  poorly- 
arranged  when  we  consider  the  immature  condition  of  the  mind 
of  the  child  at  puberty  and  early  youth,  especially  in  dementia 
praecox,  in  which  there  is  often  a  history  of  delayed  and  defect- 
ive establishment  of  puberty.  Pickett  some  years  ago  showed 
by  statistical  studies,  made  at  the  Insane  Department  of  the 
Philadelphia  General  Hospital,  that  the  average  age  of  the 
paranoid  cases  was  greater  than  that  of  the  catatonic  cases, 
and  that  the  catatonic  cases  were  somewhat  older  than  the 
hebephrenics.  In  keeping  with  these  facts,  the  tendency  to 
systematization  is  least  evident  in  the  hebephrenics,  slightly 
more  evident  in  the  catatonics,  and  most  developed  in  the 
paranoid  cases. 

The  mode  of  onset,  especially  when  the  \atter  pursues  the 
more  common  gradual  course,  permits  of  the  preservation  for 
a  longer  or  shorter  period  of  a  relatively  high  degree  of  lucidity; 
this  lucidity  becomes  impaired  in  proportion  as  disturbed  and 
hallucinatory  states,  on  the  one  hand,  or  stuporous  states,  on 
the  other,  are  established.  During  this  relative  lucidity,  per- 
ception is  good;  illusions,  as  already  pointed  out,  are  infre- 
quent, often  altogether  absent.  It  is  not  surprising,  therefore, 
that  under  these  circumstances  orientation  should  be  well 
preserved;  the  patient  correctly  appreciates  and  correctly 
correlates  himself  wdth  his  surroundings. 

In  keeping  with  the  above  facts  are  also  the  facts  of  memory. 
Memory  is  good,  well  preserved,  indeed,  for  the  period  pre- 
ceding the  onset.  It  may  be  fairly  good  for  events  during  the 
early  stage,  and,  like  the  lucidity  and  orientation,  may  show 
impairment  or  loss  only  during  and  for  the  periods  of  the  dis- 
turbed or  stuporous  states.  Of  course,  in  the  stage  of  terminal 
impairment,  if  such  be  the  outcome,  the  memory  suffers  along 
with  the  other  faculties. 

Again,  as  already  stated,  the  child,  as  the  affection  makes 


GROUP    III — THE    HEBOID-PAKANOID    AFFECTIONS  121 

itself  manifest,  ceases  to  be  able  to  acquire  new  facts,  or  is  not 
able  to  properly  coordinate  them  with  those  already  acquired. 
It  is  not  surprising  that  the  judgment  of  the  patient,  especially 
in  regard  to  new  experiences,  becomes  impaired.  If  the  depres- 
sion of  function,  if  the  stand-still  of  mental  progress  continues, 
the  child  ceases  to  comprehend  properly  and  uniformly.  Its 
mental  reactions  and  its  will  become  impaired.  Emotional 
indifference  and  apathy,  already  mentioned,  make  their  appear- 
ance, as  does  also  indifference  to  the  surroundings.  There 
is  under  these  conditions — conditions  probably  of  exhaustion 
and  intoxication — a  loss  both  of  the  will  and  the  power  to  per- 
form the  daily  tasks.  For  the  same  reason  the  self-control,  the 
inhibition,  is  lessened  or  lost,  and  impulses  born  of  the  delusive 
ideas  may  be  given  free  vent.  Sometimes  under  these  condi- 
tions the  patient  may  become  much  disturbed,  violent,  noisy, 
destructive,  and  even  dangerous.  Sometimes,  too,  he  may 
attempt  to  injure  himself  or  to  commit  suicide. 

As  the  affection  progresses  the  patient  may,  as  already  stated, 
become  more  and  more  quiet,  talk  less  and  less,  or  finally  be- 
come mute.  A  stuporous  state  may  supervene  which  resembles 
simple  stupor,  or  it  may  be  accompanied  by  automatism,  the 
patient  remaining  in  positions  in  which  he  happens  to  be  placed, 
or  he  assumes  spontaneously  fixed  positions  with  rigidity, 
a  catatonia  making  its  appearance. 

At  times  automatism  at  command  is  present,  the  patient 
walking,  standing  still,  or  performing  other  simple  acts  very 
much  as  a  person  under  hypnosis.  At  other  times  a  condition 
of  negation  is  developed — "negativism"  as  it  is  called.  The 
patient,  instead  of  complying  with  an  instruction,  performs 
exactly  the  opposite  act;  thus,  if  told  to  walk  forward,  he  may 
walk  backward;  if  told  to  stand  up  he  may  sit  down,  and  vice 
vers4.     Again,  sometimes,  when  the  effort  is  made  to  change 


122  '  MENTAL    DISEASES 

the  position  of  the  patient,  marked  resistance  is  encountered. 
If  a  limb  happens  to  be  held  extended  or  flexed  and  the  effort 
is  made  to  change  it  from  one  position  to  the  other,  the  muscles 
resist,  and  as  soon  as  the  hands  of  the  physician  are  removed 
the  Umb  resumes  its  former  position.  The  positions  and  atti- 
tudes may  involve  not  only  the  limbs,  but  the  trunk  and  head 
as  well;  not  infrequently  they  are  bizarre.  Patients  often 
lie  in  the  bed,  with  the  head  drawn  upon  the  chest,  the  eyes 
closed,  the  limbs  flexed,  or  in  other  fixed  positions,  giving  vent 
to  no  word  or  sound,  resisting  the  taking  of  food,  and  retaining 
both  urine  and  feces.  Every  now  and  then  such  a  picture  of 
immobility  is  broken  in  upon  by  an  activity  apparently  as 
purposeless  as  it  is  sudden.  Occasionally  the  patient  repeats 
the  same  movements  or  group  of  movements  many  times;  he 
rocks  to  and  fro,  repeats  the  same  gestures,  makes  the  same 
movements  with  the  hands  or  taps  upon  the  wall  or  bed.  Just 
as  there  may  be  stereotjT)ed  positions,  so  may  there  be  stereo- 
typhy  of  movements.  In  catatonia,  the  patient  may  repeat  the 
same  word  or  words,  the  same  phrase  or  sentence — often  with- 
out meaning  or  apparently  senseless — continuously  for  hours, 
then  presenting  the  symptom  termed  verbigeration. 

At  other  times,  the  patient's  restlessness  finds  its  vent  in 
grotesque  and  extravagant  capers.  The  patient  jumps  up  and 
down,  claps  his  hands,  bounds  about  the  room,  rolls  about  the 
bed,  tosses  hither  and  thither.  It  would  seem  that  the  motor 
excitement  here  presented  is  the  outcome  of  a  sheer  physical 
exuberance  and  is  probably  the  expression  of  an  expansive 
phase.  At  times,  again,  the  restlessness  finds  its  vent  in  a 
bizarre,  silly,  outlandish,  or  clo^vnish  conduct.  Frequently, 
too,  the  patient  makes  grimaces,  snuffles,  clicks  his  tongue,  or 
makes  other  curious  sounds.  Often  he  smiles  or  laughs  cause- 
lessly.    Like  the  grimaces,  the  laughter  seems  to  bear  no  rela- 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  123 

tion  to  any  corresponding  emotion.  It  is  in  keeping  with  other 
expressions  and  gestures  which  seem  to  bear  either  no,  or  a 
perverted,  relation  to  the  mental  content.  They  appear  to  be 
groups  of  associated  movements,  the  result  of  the  spontaneous 
emission  of  impulses  which  are  uninhibited. 

Cases  of  dementia  praecox  manifest  their  increasing  mental 
deterioration  in  various  ways.  Early  in  the  ajffection  they 
manifest  neglect  and  indifference  to  their  persons;  as  the  dis- 
ease progresses,  they  manifest  a  loss  of  the  finer  feelings, 
aesthetic  qualities,  shame,  sympathy,  affection  for  their  rela- 
tives. Their  habits  degenerate;  they  eat  voraciously,  noisily, 
and  without  proper  use  of  table  utensils.  Later  they  become 
unclean  and  filthy  in  their  habits;  they  may,  as  do  other  de- 
mented patients,  soil  the  bed  or  clothing,  urinate  upon  the  floor, 
smear  the  fecal  matter  upon  the  hands  or  person,  or  even  in- 
troduce it  into  the  mouth,  nose,  or  ears.  Masturbation  is  also 
a  common  feature. 

The  physical  signs  of  dementia  praecox,  in  addition  to  the 
motor  phenomena  already  considered,  are  not  numerous.  In 
the  early  stages,  station  and  gait  are  not  altered;  there  is  no 
tremor;  the  tendon  reflexes  may  show  no  change,  save  that  at 
times  they  are  exaggerated.  The  pupils  are  frequently  much 
dilated,  especially  in  the  stages  of  excitement.  They  appear 
throughout  to  be  larger  than  normal.  Sometimes  the  pupils 
undergo  remarkable  and  sudden  changes  in  diameter.  In- 
equality of  the  pupils  does  not  seem  to  occur.  Disturbances 
of  the  light  reflex,  if  present,  are  insignificant — Bumke  is  under 
the  impression  that  in  catatonics  the  pupillary  contraction 
comes  on  more  suddenly  and  disappears  more  suddenly  than 
normally.  He  does  not,  however,  regard  the  symptom  as  of 
value,  and  does  not  venture  to  say  that  the  light  reflex  is  regu- 
larly exaggerated.     Reaction  to  accommodation  is  undisturbed. 


124  MENTAL    DISEASES 

However,  a  condition  which  Bumke  would  regard  as  typical 
for  dementia  praecox  is  the  absence  of  the  psychic  reflex;  i.  e., 
the  movements  of  the  iris  in  response  to  the  play  of  concepts 
and  emotions;  also  the  reduction  of  the  pupillary  motihty  and 
the  absence  of  dilatation  to  sensory  stimulation.  These  con- 
ditions appear  to  obtain  in  cases  already  long  estabUshed,  and 
in  which  there  are  present  psychic  enfeeblement  and  more  or 
less  general  deterioration. 

Sleep  is,  as  a  rule,  much  disturbed,  especially  during  the 
period  of  evolution.  The  appetite  is  usually  diminished  at 
first,  though  later  on  it  may  be  increased  and  even  excessive. 
There  are  present  quite  frequently  the  signs  of  an  atonic  indi- 
gestion with  constipation;  at  other  times  these  features  are 
absent.  The  circulation  is  quite  commonly  depressed;  often 
we  find  the  surface  cool,  the  extremities  cold  and  livid,  the 
features  dusky,  the  pulse  rate  increased ;  on  the  other  hand,  as 
in  the  case  of  the  digestive  tract,  no  symptoms  of  moment  may 
be  noted.  Among  special  features,  it  should  be  added,  we  ob- 
serve in  dementia  praecox,  with  a  suggestive  frequency,  enlarge- 
ment of  the  thjToid  gland.  The  body  weight  is,  as  a  rule, 
decidedly  below  normal. 

As  the  reader  may  have  inferred,  the  pictures  presented  by 
individual  cases  of  dementia  praecox  vary  greatly;  that  they, 
however,  present  an  underlj-ing  uniformity  and  identity  is 
equally  clear,  and  the  general  description  of  periods  of  depres- 
sion and  expansion,  with  confusion  and  deterioration,  must  be 
regarded  as  fairly  applicable  to  all.  The  recurrence  of  a  cycle 
of  depression  and  expansion  after  an  interval  of  improvement, 
especially  if  this  interval  be  short  so  that  an  expansive  wave  is 
more  or  less  closely  antecedent  to  a  depressive  wave,  may  give 
rise  to  the  incorrect  inference  that  the  expansive  wave  was 
first  in  the  order  of  sequence;   especially  may  this  be  the  case 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  125 

when  the  initial  period  of  the  disease  has  not  been  under  ob- 
servation. The  more  the  writer  has  studied  the  subject,  the 
more  he  has  become  convinced  of  the  correctness  of  Hecker's 
original  interpretation. 

As  was  pointed  out  in  the  beginning  of  this  chapter,  and  re- 
peatedly called  to  mind  in  our  general  consideration  of  the 
subject,  dementia  prsecox  embraces  hebephrenia,  catatonia, 
and  paranoid  dementia.  These  forms,  while  closely  related, 
present,  notwithstanding,  special  clinical  features.  We  will 
first  turn  our  attention  to  hebephrenia. 

DISTINGUISHING  FEATURES   OF  THE   SIMPLE  OR  HEBEPHRENIC 

FORM 

The  symptomatology  of  dementia  praecox,  as  a  whole,  having 
been  already  considered  in  some  detail,  it  is  necessary  only  to 
point  out  briefly  the  special  features  appertaining  to  hebe- 
phrenia. To  begin,  in  hebephrenia  the  symptoms  of  dementia 
praecox  are  generalized  in  type;  the  characteristics  of  the  more 
differentiated  forms,  catatonia  and  paranoid  dementia,  are 
lacking;  i.  e.,  there  are  absent,  more  or  less  markedly  on  the 
one  hand,  the  special  motor  phenomena — the  fixation,  re- 
sistance, negativism,  and  verbigeration — of  catatonia,  and, 
on  the  other,  the  systematized  delusions  of  paranoid  dementia. 

Second,  as  is  well  known,  and  as  was  shown  statistically 
by  Pickett,  hebephrenia  is  the  form  met  with  among  the  younger 
patients;  i.  e.,  the  youngest  group  of  all.  Consequently,  and, 
as  might  perhaps  be  justly  inferred,  the  degrees  of  the  emotional 
departures  from  the  normal  are  less  marked  than  in  catatonia 
and  paranoid  dementia.  In  other  words,  the  depth  of  the 
depressive  wave  is  apt  to  be  decidedly  less  than  in  the  other 
forms,  and  this  is  equally  true  of  the  height  of  the  wave  of 
expansion.     Sometimes    the    initial    period    is    characterized 


126  MENTAL    DISEASES 

merely  by  a  sense  of  illness,  of  hypochondriasis,  the  child  com- 
plaining of  headache,  dizziness,  obscure  bodily  distress  and 
sleeplessness,  and  manifesting  a  depression  relatively  moderate 
in  degree.  It  is  more  frequently,  too,  in  hebephrenia  that  the 
initial  period  escapes  observation,  which  would  hardly  be  the 
case  if  it  were  pronounced.  Again,  the  expansive  phase,  while 
relatively  more  marked  than  the  depressive  phase,  may  mani- 
fest itself  more  by  exuberant  and  boisterous  conduct  than  by 
expansive  delusions.  As  a  rule,  however,  both  the  initial  wave 
of  depression  and  the  subsequent  wave  of  expansion  are  clearly 
marked,  though  less  so,  on  the  whole,  than  in  the  other  forms. 

Third,  the  delusive  ideas  are  in  hebephrenia  wholly  un- 
systematized, fragmentary,  changeable,  and  transitory.  In 
this  particular  the  contrast  is  most  marked  with  the  paranoid 
form.  Doubtless  here,  among  other  factors,  the  question  of 
age  comes  into  play;  the  more  mature  the  mind,  the  more  the 
delusions  tend  to  assume  a  logical  sequence,  a  logical  structure. 

Because  of  the  generalized  t>T)e  of  hebephrenia,  I  believe  it 
is  quite  proper  to  speak  of  it  as  the  siyyiple  form  of  dementia 
praecox.  Notwithstanding,  Kahlbaum's  original  designation 
derived  from  hebe  (r]/5r/),  puberty,  and  phren  i^pr^'-'),  the 
mind,  is  of  the  very  greatest  value,  because  it  accentuates 
the  fact  of  the  early  age  of  the  patient. 

DISTINGUISHING   FEATURES    OF   THE    CATATONIC   FORM 

Catatonia  is  distinguished  by  the  fact  that  to  the  general 
symptoms  of  dementia  praecox,  already  considered,  there  are 
added  definite  motor  phenomena,  spasms,  fixed  attitudes, 
stereotyped  postures,  automatism,  negati\'ism,  verbigeration, 
stupor.  Catatonia,  according  to  Pickett's  statistical  observa- 
tions, occurs  in  a  group  somewhat  older  than  the  hebephrenics. 
In  keeping  with  this  fact,  we  find  a  well-marked  initial  wave  of 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  127 

depression  and  a  well-marked  wave  of  expansion.  The  de- 
lusions are,  as  in  hebephrenia,  unsystematized,  imfixed,  vary- 
ing, changeable,  disappearing.  Now  and  then  clearly  marked 
paranoid  references  are  met  with;  thus,  the  patient  tells  us 
that  people  are  hearing  his  thoughts,  people  are  talking  about 
him,  are  talking  of  things  he  has  done,  that  he  is  to  be  punished, 
executed,  etc.  A  true  paranoid  structure  is,  however,  not 
observed. 

The  name  catatonia,  like  the  word  hebephrenia,  is  an  ex- 
ceedingly valuable  and  well-chosen  one;  it  is  derived  from 
catateino,  (xaraT££vw),  I  stretch  tightly,  and  clearly  conveys 
the  idea  of  the  distinguishing  feature  of  the  affection. 

DISTINGUISHING  FEATURES  OF  THE  PARANOID  FORM 
Dementia  paranoides,  a  term  first  introduced  by  Kraepehn, 
is  especially  applicable  to  the  third  form  of  dementia  prsecox. 
It  presents  the  general  symptom  group  of  dementia  prsecox, 
and,  in  addition,  is  characterized  by  the  fact  that  the  delusions 
present  distinct  evidences  of  systematization,  although  this 
systematization  is  comparatively  feeble.  There  is  never, 
indeed,  the  well  developed  logical  arrangement  of  paranoia. 
The  affection  is  ushered  in  by  a  preliminary  period  of  depression, 
weakness,  general  fatigue,  headache,  and  sleeplessness.  Very 
soon  the  patient  becomes  actively  disturbed.  He  is  restless, 
agitated,  suspicious,  and  delusional.  People  are  watching 
him,  talking  about  him,  he  is  in  danger,  he  is  about  to  be 
poisoned,  is  threatened  with  torture,  fire,  murder.  At  the  same 
time,  painful  auditory  hallucinations  manifest  themselves; 
there  may  also  be  hallucinations  of  vision  and  of  the  other 
special  senses.  Delusions  of  persecution,  in  part  confused 
and  disordered,  in  part  coordinated  and  systematized,  now 
dominate  the  picture.     The  hallucinations  and  delusions  alike 


128  MENTAL    DISEASES 

are  painful,  and  the  patient  clearly  and  definitely  refers  his 
sufferings  to  agencies  in  the  external  world.  Sometimes  ideas 
of  crime,  misdeeds,  or  transgression  on  the  part  of  the  patient 
make  their  appearance,  but  they  serve  only  to  explain  his  per- 
secution. Similarly,  the  ideas  sometimes  have  a  hypochon- 
driacal basis,  and  the  patient  believes  that  he  is  persecuted 
because  he  has  some  terrible  illness,  some  dreadful  deformity. 
That,  in  his  efforts  to  escape  his  persecution,  he  may  now  and 
then  attempt  suicide  is  not  surprising,  but  much  more  fre- 
quently the  paranoid  dement  is  dangerous  to  others,  sometimes 
exceedingly  so.  Assaults  upon  the  persons  about  them — 
relatives,  friends,  attendants — are  common  occurrences. 

After  a  time,  variable  in  duration,  and  usually  not  very  long 
— weeks  or  months — it  is  noted  that  the  patient  is  becom- 
ing expansive,  and  this  change  is  gradually  more  and  more 
marked.  The .  patient  becomes  talkative,  boastful,  believes 
himself  to  be  a  person  of  consequence;  sometimes  claims,  as  in 
paranoia  itself,  that  he  is  not  the  person  he  is  supposed  to  be, 
that  he  has  suffered  substitution  in  the  cradle,  that  he  is  of 
noble  or  of  royal  birth,  that  he  is  very  powerful,  omniscient,  a 
great  discoverer,  a  great  inventor,  or  perhaps  that  he  has  a 
mission  to  perform,  a  revelation  from  the  Deity  to  communi- 
cate. The  various  delusions  seem  to  follow  without  relation 
to  each  other.  Apparently  they  are  based  haphazard  upon 
the  hallucinations  and  upon  the  misinterpreted  sense  impres- 
sions. A  word,  a  gesture,  a  fancied  resemblance,  is  enough 
to  give  rise  to  the  most  phantastic  train  of  ideas.  Perhaps  it 
is  just  because  they  are  varied  and  multiple  that  the  delusions 
lack  the  coordination  seen  in  paranoia.  However,  as  in  the 
latter  affection,  the  patient  may  find  in  his  grandeur  and  great- 
ness the  explanation  of  his  persecution.  Again,  as  might  be 
expected,  the  delusions  lack  the  fixation  of  paranoia;  the  trend 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  129 

of  the  ideas,  however,  continues  to  be  the  same,  and  this  per- 
sists during  the  disturbed  period  of  the  affection.  Occasion- 
ally, though  rarely,  hallucinations  appear  to  be  absent  or  are 
very  slightly  marked;  in  such  cases  the  delusions  appear  to 
be  evolved  from  illusions  of  sense,  from  gross  misinterpretation 
of  things  seen,  heard,  or  read,  just  as  in  certain  forms  of  para- 
noia. They  do  not  differ  from  delusions  which  have  their 
basis  in  hallucinations;  they  are  alike  varied  and  multiple. 
In  by  far  the  greater  number  of  cases,  however,  hallucinations 
are  present,  the  auditory,  as  already  indicated,  predominating; 
when  visual  hallucinations  are  prominent,  the  delusions,  as 
in  the  case  of  paranoia,  are  apt  to  deal  vnih  mystic  ideas  and 
subjects. 

The  course  of  dementia  paranoides  is,  in  general  terms,  like 
that  of  the  other  forms;  i.  e.,  a  depressive  period,  an  expansive 
period,  together  with  a  progressive  mental  impairment.  Its 
close  relations  with  the  other  forms  of  dementia  prsecox  is 
shown,  not  only  by  its  course  and  general  symptomatology, 
but  also  by  the  not  infrequent  occurrence  of  catatonic  phe- 
nomena, such  as  fixed  positions  and  resistive  and  even  stu- 
porous states.  Further,  it  bears  equally  close  relations  to 
the  paranoias,  and  occupies,  as  it  were,  a  median  position  in 
the  series  of  affections  comprising  the  heboid-paranoid  group. 
It  may,  with  perfect  propriety,  be  spoken  of  as  "heboid  para- 
noia." 

It  is  sometimes  difficult  to  obtain  a  clear  historj^  of  the 
period  of  depression  in  dementia  paranoides,  probably  because 
the  patient  has  not  been  under  competent  observation,  and 
also  because  this  period  is  at  times  relatively  short.  At  the 
time  the  patient  comes  under  institution  observation,  expansive 
ideas  may  have  already  made  their  appearance,  and  the  false 
impression  may  be  gained  that  the  expansive  phase  is  the  first 

9 


130  MENTAL    DISEASES 

phase  of  the  attack.  Again,  the  patient  may  be  in  a  stage  of 
transition  and  persecutory  and  expansive  ideas  may  both  be 
present;  one  group  and  at  times  another  may  be  more  promi- 
nent. The  course,  too,  is  sometimes  quite  irregular.  Finally, 
the  course  is  at  times  relatively  rapid;  particularly  may  this 
be  true  of  the  period  of  evolution.  It  is  this  fact  which  has 
led  the  French  writers  to  describe  the  affection  under  such 
names  as  "delires  systematises  aigus"  and  "delires  systematises 
d'embl^e"  (Magnan),  while  the  Germans  have  applied  to  it 
such  expressions  as  ''acute  Verriicktheit,"  "acuter  Wahnsinn" 
(Schiile),  "paranoia  acuta"  (Mendel,  Schiile).  All  of  these 
expressions  imply  a  symptom  group  which,  both  in  its  develop- 
ment and  progress,  is  much  more  rapid  than  that  seen  in  para- 
noia; indeed,  there  is  a  distinct  contrast  in  this  respect  between 
paranoid  dementia  and  paranoia,  the  course  of  which  is  of 
course  essentially  chronic.  The  reader  must  not,  however, 
infer  that  the  evolution  of  paranoid  dementia  is  sudden,  for 
this  is  not  the  case;  it  is  always  gradual.  There  is  always 
a  preliminary  period  of  illness  and  depression — often  long 
before  the  symptoms  become  so  striking  as  to  attract  lay 
attention.  Again,  the  fact  that  simple  active  confusion 
(Verwirrtheit,  Amentia,  see  p.  49)  has  at  times  been  mis- 
taken for  this  form  of  mental  disease  has  still  further  lent 
color  to  the  idea  of  rapidity  of  onset  and  course. 

General  Considerations;  Prognosis,  and  Conclusions. — 
The  conception  of  dementia  pra3cox,  which  I  have  endeavored 
to  outline  in  the  preceding  pages,  is  that  of  an  organism  which 
has  its  beginnings  in  a  germ  plasm  defective  and  abnormal  and 
the  subsequent  development  of  which  is  necessarily  imperfect 
and  deviate.  This  means  that  the  organism  as  a  whole  is  in- 
volved. This  fact  must  be  inferred  also  from  the  presence  of 
such  evidences  of  morphologic  deviation  as  are  visible  to  clinical 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  131 

observation;  these  merely  imply  that  other  and  fundamental 
deviations  are  present  in  the  organism  throughout.  Such  an 
organism  must  present  not  only  abnormaUties  of  its  structure, 
but  also  abnormalities  of  function  and  especially  of  its  metab- 
ohsm.  Various  facts  point  to  anomalies  of  the  internal  secretions. 
For  instance,  it  is  not  infrequently  noted,  as  already  stated, 
that  the  thyroid  gland  varies  in  size  from  the  normal;  frequently 
it  is  unusually  small,  though  occasionally  enlarged.  Autopsies 
have  shown  (Dercum  and  ElUs)  that  it  is  frequently  only  half  the 
normal  weight,  while  the  adrenals  are  frequently  double  the 
normal  weight.  The  role  that  other  glands,  especially  the  thy- 
mus, may  play  in  dementia  praecox,  has  been  pointed  out  by 
Sajous;  the  function  of  the  thymus  in  the  general  development 
of  the  organism  attains  here  a  special  significance  in  view  of  the 
fact  of  morphologic  arrest  and  deviation.  The  occurrence  of 
osteomalacia  in  dementia  prsecox  as  noted  by  Barbo  and  Haber- 
kandl  must  also  be  borne  in  mind.  It  is  extremely  probable, 
that  the  entire  chain  of  ductless  glands  may  participate. 
CUnically,  our  attention  is  strongly  attracted  to  the  sex  glands. 
There  are  the  anomahes  of  menstruation,  the  delayed  and  imper- 
fect establishment  of  puberty  on  the  one  hand,  or  of  sexual 
precocity  on  the  other.  Again,  there  is  the  history  of  sexual 
excesses,  sexual  vagaries,  and  perversions.  A  relation  to  the 
sex  glands  is  further  indicated  by  the  accentuation  of  symp- 
toms often  observed  during  a  menstrual  epoch  and  by  the  fact 
that  dementia  praecox  now  and  then  has  its  incidence  in  a 
pregnancy  or  in  repeated  pregnancies,  or  in  a  miscarriage,  as 
though  sex-gland  exhaustion  played  a  role.  Tsisch,  Lomer,  and 
KraepeHn  have  all  assigned  importance  to  the  sex  glands. 
Lomer  particularly  indicated  a  disturbance  of  the  internal 
secretion  of  the  latter,  but  it  remained  for  Fauser  to  throw  an 
especially  illuminating  light  upon  the  subject.    It  would  appear 


132  MENTAL    DISEASES 

from  Fauser's  investigations  that  in  dementia  prsecox  unchanged 
sex  gland  protein — an  abnormal  internal  secretion  of  the  sex 
gland — enters  the  blood,  and  that  in  the  subsequent  breaking 
up  of  this  protein,  substances — defensive  ferments — are  formed 
which  are  poisonous  to  cortical  tissue  and  which  bring  about 
the  destruction,  the  lysis,  of  the  latter.  Fauser's  results  have 
been  confirmed  by  a  large  number  of  other  investigators.  What- 
ever the  future  may  reveal,  there  is  no  escape  from  the  conclusion 
that  in  dementia  prsecox  there  is  a  deranged  metabolism,  an 
autotoxic  state,  in  which  abnormalities  of  the  internal  secretions 
play  a  dominant  role;  that  the  internal  secretions  of  the  sex 
glands  are   especially  involved   is  extremely   probable. 

The  prognosis  of  dementia  prsecox  is,  as  may  be  inferred,  on 
the  whole  unfavorable.  However,  the  following  facts,  which 
modify  sometimes  in  a  sUght  degree,  sometimes  in  a  great  degree 
the  eventual  outcome,  must  be  borne  in  mind.  First,  the  patient 
may  pass  through  an  attack,  with  its  phases  of  depression  and 
expansion  and  the  other  attendant  mental  phenomena,  without 
presenting  at  the  end  of  the  attack  any  recognizable  mental 
impairment.  This  is  distinctly  the  exception,  but  it  does 
occur.  However,  an  increasing  clinical  experience  has  shown 
that  the  cases  in  which  recovery  had  been  believed  to  have 
taken  place  quite  frequently  suffer  a  recurrence  of  symptoms, 
sometimes  after  a  number  of  months,  sometimes  after  several 
years,  and  that  after  such  recurrence  the  mental  deterioration 
is  usually  pronounced.  This  truth  applies  not  only  to  hebe- 
phrenia, but  to  catatonia  and  paranoid  dementia  as  well.  It 
was  for  a  long  time  thought  that  the  cases  of  paranoid  dementia, 
or  acute  paranoia  (delires  systematises  aigus),  as  they  were 
earher  called,  not  infrequently  terminated  in  recovery.  Par- 
ticularly was  this  the  view  of  the  French  writers,  who  believed 
that  a  favorable  outcome  was  quite  common.     However,  the 


GROUP    III THE    HEBOID-PARANOID    AFFECTIONS  133 

fact  of  repeated  recurrences,  each  attended  by  unmistakable 
and  increasing  mental  deterioration,  has  demonstrated  that 
paranoid  dementia  is  no  exception  to  the  rule,  and,  as  in  the 
other  forms,  a  terminal  period  of  dementia  with  some  persist- 
ence of  delusions  and  confusion  finally  supervenes. 

One  must  not,  however,  go  too  far  in  such  a  generalization  as 
the  above.  Cases  are  met  with  in  which  recurrences  are  not 
observed,  or,  if  occurring,  finally  cease  to  make  their  appearance. 
For  example,  a  young  man  of  nineteen  passed  through  a  typical 
attack  of  hebephrenia.  His  case  was  relatively  mild,  and,  with 
the  aid  of  competent  nurses,  rest,  and  physiologic  measures, 
was  treated  successfully  outside  of  the  asylum,  the  entire 
attack  lasting  something  less  than  a  year.  He  was  apparently 
entirely  well.  Two  years  later  he  entered  upon  a  business 
enterprise,  married,  and  conducted  himself  in  an  apparently 
normal  manner.  However,  after  the  lapse  of  another  year,  it 
was  found  that  he  was  not  giving  the  necessary  attention  to 
his  affairs,  and  soon  that  they  were  badly  neglected.  It  was 
again  recognized  that  he  was  not  well,  and  he  was,  as  before, 
brought  under  medical  observation.  Soon  persecutory  ideas, 
ideas  of  danger,  of  harm  to  himself  and  others,  became  mani- 
fest, and  before  long  the  patient  became  violently  disturbed. 
His  condition  was  so  much  worse  than  during  the  previous  at- 
tack that  commitment  to  an  asylum  became  necessary.  Here 
he  remained  for  some  eighteen  months,  when  he  again  appeared 
to  have  recovered.  The  "recovery"  still  exists,  although  ten 
years  have  elapsed.  However,  in  order  that  the  story  should 
be  completed,  it  must  be  added,  that  he  has  never  re-entered 
business;  that  he  has  never  taken  up  any  occupation;  that, 
though  apparently  rational  and  lucid,  he  spends  his  time  in 
idleness,  in  dawdling,  and  in  trifling  pastimes,  reads  little  or 
none,  is  indifferent  and  inactive,  and  also  headstrong,  obstinate, 


134  MENTAL    DISEASES 

wilful,  and  unreasonable.  Such  a  case  can  hardly  be  looked 
upon  as  one  of  recovery.  Further,  other  symptoms  later 
appearing  strongly  suggest  that  the  patient  is  passing  into  a 
confirmed  paranoid  attitude. 

In  other  words,  a  case  of  dementia  prsecox  may  recover,  but 
the  recovery,  as  already  stated,  is  rarely  complete.  Quite 
commonly,  even  in  the  most  favorable  cases,  some  evidences 
of  mental  deterioration — deterioration  of  general  mental  make- 
up, efficiency,  and  character — are  noted.  It  must  be  confessed 
that  sometimes  these  are  very  slight  and  perhaps  non-existent, 
but  this  is  certainly  the  great  exception.  Mental  impairment 
is  ordinarily  left  in  a  recognizable  degree;  quite  commonly 
this  impairment  is  decided,  so  that  a  partial  or  incomplete 
recovery  results.  In  other  cases  again,  and  indeed  the  larger 
number,  the  mental  loss  is  profound  and  the  final  result  is  one 
of  a  terminal  and  persistent  dementia.  There  may  for  a  long 
time  be  some  persistence  of  confusion  and  delusions  and  of 
other  mental  phenomena,  but  finally  even  these  disappear. 

Recovery  in  a  case  of  dementia  prsecox,  even  when  approxi- 
mating the  normal  level,  should  be  looked  upon  with  doubt. 
Quite  frequently  such  a  supposed  recovery  is  merely  a  period 
of  more  or  less  prolonged  remission.  It  is  true  that  all  alienists 
can  recall  cases  of  recoveries  without  subsequent  recurrences. 
One  such  case  was  studied  by  myself  many  years  ago;  the  boy, 
a  lad  of  fourteen,  passed  through  a  tjqDical  and  pronounced 
hebephrenic  attack  which  terminated  in  recover}^,  a  recovery 
which  was  incomplete.  Now  an  adult  in  the  late  twenties,  he 
is  unreUable,  untruthful,  without  sense  of  responsibility, 
grossly  incompetent  in  business,  without  self-restraint,  and 
given  to  alcoholic  excesses.  Quite  commonly,  in  so-called  cases 
of  recovery,  the  patient  passes  out  of  observation,  and  we  are 
Umited  to  the  rather  unsatisfactory  account  of  friends  and  rela- 
tives, or  the  case  is  definitely  lost  to  view. 


GROUP    III THE    HEBOID-PARANOID    AFFECTIONS  135 

Having  laid  emphasis  upon  tlie  unfavorable  aspects  of  the 
subject,  let  us  now  turn  our  attention  to  such  facts  as  offer 
some  encouragement.  It  is  found,  in  the  first  place,  that  cases 
of  catatonia  offer  a  distinctly  more  favorable  outlook  than  the 
other  forms.  Kraepelin's  observations  lead  him  to  state  that 
the  percentage  of  recoveries  is  about  8  per  cent,  in  hebephrenia 
and  about  20  per  cent,  in  catatonia.  While  my  own  experience 
in  regard  to  recoverable  cases  would  place  the  figures  somewhat 
higher  than  this,  it  all  depends  upon  what  is  meant  by  a  re- 
covery. Kraepelin  himself  places  the  percentage  of  recoveries 
with  impairment  much  higher.  The  practical  fact  for  us, 
however,  remains  that  quite  a  number  of  cases  get  well,  most 
frequently  with  some  traces  or  evidences  of  permanent  damage. 
The  second  question  that  confronts  us  is,  is  there  any  way  in 
which  a  favorable  outcome  can  be  foretold?  Unfortunately  the 
answer  that  can  be  returned  to  such  a  question  is  not  very 
satisfactory.  However,  it  may  be  said  that,  in  addition  to  the 
more  favorable  outlook  presented  by  catatonic  cases,  we  have, 
first,  the  relative  mildness  or  severity  of  the  attack.  If  the 
attack  be  mild,  so  mild,  for  instance,  that  the  patient  can  be 
cared  for  outside  of  an  institution,  simple  rest  in  bed,  with  full 
or  massive  feeding,  bathing,  massage,  exercise,  and  other 
physiologic  methods,  will  often  yield  surprising  results.  The 
circumstances  of  the  patient,  his  ability  to  secure  detailed 
and  elaborate  care,  are,  therefore,  factors  of  moment.  Under 
any  conditions,  however,  and,  as  might  have  been  anticipated, 
the  less  severe  the  attack,  other  things  equal,  the  more  favor- 
able the  outcome.  Secondly,  there  is  the  relative  acute- 
ness  of  onset  and  course.  Cases  that  pursue  an  acute  and 
active  course  presage,  other  things  equal,  a  lesser  duration,  and, 
therefore,  a  lessened  danger  of  permanent  change.  In  cases 
of  slow  and  relatively  chronic  course  the  danger  of  mental  cle- 


136  MENTAL    DISEASES 

terioration,  by  the  time  the  attack  is  over,  is,  other  things  equal, 
greater.  Third,  the  age  of  the  patient  is  also  important. 
Relative  early  age  or  youth  is  proportionately  favorable.  Un- 
fortunately attacks  of  dementia  prsecox  do  not  always  occur  in 
youth.  Sometimes  a  hebephrenia  does  not  set  in  until  the 
third  decade  of  life  is  well  advanced;  similarly,  a  catatonia 
may  not  put  in  an  appearance  until  the  late  thirties  or  even 
forties  are  reached.  Cases  of  late  hebephrenia  and  of  late 
catatonia  offer  a  relatively  imfavorable  prognosis;  duration 
is  especially  prolonged — often  many  years — and  the  final  out- 
come is  quite  commonly  that  of  marked  and  persistent  deteri- 
oration. 

In  regard  both  to  late  hebephrenia  and  late  catatonia,  the 
writer  is  convinced  that  the  attack  observed  is  frequently  not 
the  first  attack  of  mental  disturbance  from  which  the  patient 
has  suffered;  not  rarely  a  careful  study  of  the  patient's  early 
history  reveals  attacks  variously  diagnosticated  as  nervous 
prostration,  hypochondriasis,  hysteria,  neurasthenia,  lasting 
often  a  year  or  more.  The  inference  is  justified  that  the  attack 
observed  is  in  reahty  a  recurrence,  a  recurrence  frank  and  pro- 
nounced, but,  because  it  is  a  recurrence,  less  promising  as  re- 
gards the  outcome.  Finally,  I  am  convinced  that  an  early  and 
perhaps  improperly  diagnosticated  attack  of  hebephrenia  may 
recur  years  later  as  a  catatonia;  the  diagnosis  then  of  a  "late" 
catatonia  is  made.  It  cannot  be  sufficiently  emphasized  that 
late  attacks  of  dementia  prsecox,  no  matter  of  which  form,  offer 
an  unfavorable  outlook,  both  as  regards  duration  and  final  re- 
covery. 

The  prognosis  of  paranoid  dementia  is  deserving  of  a  final 
word.  Its  duration  extends  over  months  and  years;  i.  e., 
the  periods  of  depression  and  expansion  may  be  completed  in 
the  course  of  several  months  or  a  year  or  two,  but  the  patient 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  137 

is  left  in  a  condition  of  persistent  and  more  or  less  marked 
mental  impairment.  The  more  rapid  the  onset  and  the  more 
acute  the  course,  the  shorter,  other  things  equal,  the  attack. 
Again,  the  attack  does  not  always,  nor  necessarily,  imply  a 
subsequent  impairment  or  dementia.  Indeed,  the  patient,  as 
in  the  other  forms  of  dementia  prsecox,  may  make  a  recovery. 
Unfortunately,  just  as  in  the  other  forms,  there  is  a  well-marked 
tendency  to  recurrence;  months,  more  frequently  several 
years,  after  the  first  attack  another  may  make  its  appearance. 
This  is  apt  to  be  followed  by  evidences  of  deterioration  more 
or  less  marked.  Subsequent  attacks  emphasize  the  damage, 
or  the  affection  may  assume  a  chronic  form.  Repeated  at- 
tacks are  disposed  to  be  of  increasing  duration.  Finally,  in 
the  recurrences  the  periods  of  depression  and  expansion  may 
not  be  clearly  outlined;  persecutory  and  expansive  ideas  may 
be  commingled,  or  the  expansive  phase  may  even  present  the 
fallacious  appearance  of  preceding  the  depressive. 

There  can  be  no  doubt  that  the  French  observers  w^ere  cor- 
rect in  regard  to  recovery  from  a  first  attack.  It  is  the  un- 
fortimate  fact  of  recurrence  that  militates  against  persistent 
and  eventual  recovery.  As  in  the  other  forms  of  dementia 
prsecox,  we  are  governed  by  the  severity  and  the  acuteness 
of  the  attack,  and,  to  a  somewhat  lesser  extent,  by  the  factor 
of  age.  Two  additional  and  important  facts  must  also  be 
borne  in  mind;  first,  the  more  the  picture  resembles  merely 
an  active  confusion,  and  the  less  marked  the  tendency  to 
systematization,  the  more  favorable,  other  things  equal,  the 
outlook;  second,  the  presence  of  anything  suggesting  per- 
sistence or  fixation  of  delusions  is  distinctly  unfavorable.  Fi- 
nally, it  should  be  repeated  that  cases  are  not  wanting — cases 
usually  of  a  subacute  course — which,  though  beginning  as 
paranoid  dementia,  and  probably  passing  through  a  series  of 


138  MENTAL    DISEASES 

recurrences,  gradually  pass  into  a  chronic  form  and  eventuate 
as  a  paranoia  hallucinatoria.  This  transition  is  infrequent, 
but  there  is  no  good  reason  to  doubt  its  occurrence.  It 
has  been  denied  by  Krafft-Ebing  and  by  Magnan,  but  has 
been  affirmed  by  Mendel,  Westphal,  Schiile,  Legrain,  and 
others.  There  is  here  a  link  of  transition  between  the  paranoid 
form  of  dementia  prsecox  and  the  paranoias.  In  other  words, 
just  as  hebephrenia,  catatonia,  and  paranoid  dementia  are  re- 
lated to  each  other,  so  is  the  paranoid  form  related  to  the  re- 
maining members  of  the  heboid-paranoid  group. 

In  conclusion  it  is  hardly  necessary  to  point  out  that  the 
clinical  pictures  presented  by  individual  cases  of  dementia 
praecox  vary  greatly.  Kraepelin  has  distinguished  no  less  than 
ten  forms;  thus,  a  form  characterized  by  simple  dementia; 
secondly,  a  form  characterized  b}^  impairment  with  silliness; 
thirdly,  by  impairment  with  depression  and  it  may  be  stupor; 
fourth,  impairment  with  depression  and  delusions;  fifth,  a 
circular  form;  sixth,  an  agitated  form;  seventh,  a  periodic 
form;  eighth,  catatonia;  ninth,  the  paranoid  forms,  and  finally 
a  form  characterized  especially  by  confusion  of  speech.  Kraepe- 
lin, however,  prefaces  the  descriptions  which  he  gives  by  the 
statement  that  between  the  various  forms  there  are  so  many 
transitional  forms  that  they  cannot  be  sharply  delimited.  He 
regards  them  merely  as  more  frequently  recurring  pictures  and 
does  not  ascribe  to  them  a  higher  clinical  value.  Detailed 
clinical  studies  will  add  greatly  to  our  knowledge,  but  it  may  be 
safely  stated  that  the  original  grouping  into  the  hebephrenic, 
the  catatonic,  and  the  paranoid  forms  may  be  considered  as 

established. 

PARANOIA 

French  writers,  under  the  term  "delires  systematis^s  chron- 

iques,"  have  described  a  mental  affection  which,  in  contrast 

to  the   "delires  systematis6s  aigus"    (paranoid   dementia),  is 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  139 

of  slow  evolution,  runs  a  chronic  course,  and  is  characterized 
by  a  logical,  an  orderly,  arrangement  of  the  delusive  beliefs; 
i.  e.,  by  systematization  of  the  delusions.  Our  knowledge  of 
this  subject  is  of  gradual  growth,  and  the  original  observa- 
tions of  Laseque  (1852),  Morel  (1860),  Falret  pere  (1864), 
Falret  fils  (1878),  and  others  were  no  less  epoch-making  than 
the  studies  of  Kahlbaimi  and  Hecker  in  hebephrenia  and  cata- 
tonia. In  England  it  was  more  particularly  Savage  who  first 
clearly  grasped  the  subject,  terming  the  affection  delusional 
insanity.  Among  the  Germans  it  was  Westphal,  and  later 
Krafft-Ebing  and  Schiile,  who  differentiated  the  sjrmptom 
complex;  unfortunately,  they  employed  the  rather  ill-defined 
words  "Verriicktheit"  and  ''Wahnsinn"  in  describing  it,  terms 
which  led  subsequently  to  much  confusion.  It  was  here  that 
Mendel  rendered  a  signal  service  to  psychiatry.  The  word 
paranoia  {jzapdvo-.a)  was  used  by  Aristotle,  Plato,  Aeschylus, 
and  doubtless  by  other  writers,  in  the  sense  of  derangement, 
madness,  folly,  obstinacy,  perversity.  It  resolves  itself  into 
the  two  roots  -apa,  beyond,  and  voo^^  mind.  It  found  its 
way  into  German  fiterature  late  in  the  eighteenth  century 
(1764),  when  Vogel  applied  it  rather  indefinitely  to  what  was 
apparently  melanchoha  and  mania.  Later  Heinroth  (1818) 
described,  under  the  term  paranoia,  a  condition  of  "lack  of 
freedom  of  mind  with  exaggerated  obstinacy  in  conception 
and  judgment."  It  was  Mendel  who  first  gave  to  the  word  a 
definite  application,  and  it  quickly  replaced  its  predecessors, 
Verrticktheit  and  Wahnsiim,  and  became  sjmonymous  with 
the  delire  systematise  of  the  French  and  the  delusional  lunacy 
of  the  English  TVTiters.  It  is  now  a  term  generally  accepted  as 
meaning  insanitj^  ^dth  systematized  delusions  and  chronic  in 
course.  Among  the  older  terms,  now  displaced,  may  be  men- 
tioned monomania  and  partial  insanity,  both  of  them  expres- 
sions based  upon  erroneous  conceptions  of  the  affection. 


140  MENTAL    DISEASES 

As  may  be  anticipated,  delusional  lunacy  or  paranoia  mani- 
fests itself  in  a  number  of  ways.  The  various  forms  can,  how- 
ever, be  conveniently  grouped  under  two  heads:  first,  a  form 
in  which  the  delusions  are  intimately  associated  with  hallucina- 
tions, and,  second,  a  form  in  which  the  delusions  are  evolved 
independently  of  or  in  the  absence  of  hallucinations.  Roughly 
speaking,  paranoia  resolves  itself  into  a  hallucinatory  and  a 
non-hallucinatory  form. 

There  has  been  a  tendency  for  some  years  past,  following  the 
lead  of  Kraepelin,  to  greatly  restrict  the  use  of  the  word  paranoia. 
Under  the  general  caption  of  paranoia,  Kraepelin  at  first 
embraced  both  of  the  above  forms.  The  first,  in  which  the 
delusive  beliefs  apparently  arose  independently  of  hallucina- 
tions and  seemed  to  be  formed  by  the  combination  of  actual  sense 
impressions,  he  termed  the  "combinatorische"  form;  the  second, 
in  which  the  delusions  apparently  arose  in  association  with 
hallucinations,  he  termed  the  "phantastic"  form.  I>ater  he 
placed  this  phantastic  form  under  the  caption  of  dementia 
prsecox,  now  calling  it  a  "second"  form  of  paranoid  dementia. 
Later  still,  in  the  eighth  edition  of  his  Psychiatry,  he  again 
removed  it  from  under  the  caption  of  dementia  prsecox  and 
gave  it  an  independent  position  in  his  nosology.  He  now  gave 
it  the  name  "paraphrenia."  Unfortunately,  however,  para- 
phrenia has  exactly  the  same  meaning  as  paranoia  and  suffers 
the  further  disadvantage  of  being  an  artificially  made  word. 
In  the  opinion  of  the  writer,  the  affection  should  unhesitatingly 
be  included  under  the  general  caption  of  paranoia,  being  best 
characterized  as  the  "hallucinatory"  form.  Further,  between 
it  and  the  so-called  non-hallucinatory  form,  there  are  close 
relationships;  as  will  become  apparent  later.  While  individual 
cases  vary,  the  underlying  features  are  always  the  same,  and 
the  writer  believes  that  alienists  would  do  well  to  retain  the 
word  paranoia  in  the  original  signification  in  which  Mendel 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  141 

first  emploj^ed  it.  It  stands  for  a  definite  thing;  namely,  system- 
atized delusional  lunacy. 

In  general  terms,  paranoia  differs  from  the  other  members  of 
the  group  thus  far  considered,  as  follows:  first,  its  delusions 
are  systematized,  i.  e.,  they  have  a  clearly  marked  logical  struc- 
ture, are  logically  arranged  and  coordinated;  second,  the 
affection  is  of  exceedingly  slow  evolution  and  course;  third, 
it  is  an  affection  of  adult  life.  As  before,  there  is  an  initial 
period  of  depression,  but  this  period,  instead  of  extending  over 
a  number  of  months  only  or  perhaps  a  year  or  so,  now  extends 
over  many  years.  As  before,  there  is  a  transition  to  an  ex- 
pansive period.  The  transition  is,  for  the  most  part,  gradual, 
and  is  often  spoken  of  as  "the  transformation  of  the  per- 
sonality." The  subsequent  period  of  expansion,  like  the  period 
of  depression,  is  also  of  many  years'  duration.  Paranoia  is, 
therefore,  practically  a  life-long  disease.  Finally,  like  the  other 
members  of  this  group  of  affections,  its  progress  is  attended  by 
a  gradual  deterioration,  an  increasing  dementia.  In  some 
cases,  more  especially  of  the  hallucinatory  form,  the  progress 
may  be  interrupted,  though  rarely,  by  remissions  or  partial 
remissions  of  symptoms,  these  remissions  giving  way  later  to 
recurrences,  just  as  in  the  other  members  of  the  heboid-paranoid 
group.  Again,  in  many  cases,  the  dementing  change  progresses 
steadily  and  even  obviously  rapidly;  in  others,  especially  in 
the  non-hallucinatory  form,  the  deterioration  often  takes  place 
with  exceeding  slowness.  Finally,  as  might  be  expected,  in 
some  cases,  the  patient  remains  in  the  period  of  depression — 
often  spoken  of  as  the  period  of  persecution — during  the  entire 
time  that  he  is  under  observation,  the  expansive  period  never 
being  reached. 

In  paranoia  the  general  truth,  already  pointed  out  in  the 
beginning  of  this  chapter  in  regard  to  the  role  of  heredity,  finds 
its  full  expression.     Hereditary  factors  are  here  the  order  of 


142  MENTAL    DISEASES 

the  day,  and  85  or  90  per  cent,  is  probably  a  moderate  estimate. 
That  the  patient  has  had  transmitted  to  him  or  is  the  victim  of 
a  defective  and  aberrant  organization  may  also  be  evidenced 
by  the  presence  of  gross  morphologic  arrests  and  deviations. 
Such  morphologic  features  occur  in  paranoiacs  with  suggestive 
frequency.  Sometimes  the  skull  presents  a  markedly  flattened 
occiput;  sometimes  it  is  oxycephalic,  strikingly  asymmetric, 
or  presents  some  other  abnormal  trait.  It  may  be  that  the 
trunk,  the  hmbs,  or  the  digits  reveal  peculiarities;  perhaps 
in  relative  development;  perhaps  in  the  presence  of  feminine 
characteristics  in  male  patients,  or  of  masculine  characteristics 
in  female  patients.  Gross  anomahes  of  structure,  of  course, 
justify  the  inference  that  the  organism,  as  a  whole,  has  deviated 
from  the  normal,  and  even  when  gross  anomalies  of  structure 
are  not  evident  this  inference  may  be  justified  on  other  groimds. 
Frequently  patients  who  subsequently  develop  paranoia  betray 
already  in  their  childhood  and  youth  striking  peculiarities  of 
conduct.  They  may  be  unduly  quiet  and  reserved,  abnormally 
shy,  and  suspicious.  They  remain  apart  from  their  comrades, 
do  not  mix  in  the  play  of  other  children,  form  few  attachments, 
have  no  friends.  Often  they  are  morbidly  sensitive,  introspect- 
ive, self-conscious.  Later,  as  they  pass  through  the  period  of 
youth,  they  reveal  the  same  characters  and,  it  may  be,  in  a 
more  marked  degree;  they  keep  to  themselves,  are  distant,  dif- 
fident, taciturn,  proud,  egotistic,  at  least  always  occupied  with 
themselves.  That  a  history  of  a  morbid  childhood  and  youth 
cannot  be  obtained  in  every  case  need  hardly  be  stated.  When 
a  history  is  possible,  however,  a  patient  and  detailed  inquiry 
usually  reveals  significant  facts.  At  any  rate  the  facts  of 
heredity,  morphologic  peculiarities,  and  aberrant  childhood 
and  youth  justify  the  view  that  the  tendency  to  the  later  on- 
coming paranoid  degeneration  in  adult  life  is  already  present 
in  the  individual  at  his  birth.     In  keeping  with  this  idea,  it  is 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  143 

significant  that  paranoia  is  somewhat  more  frequent  in  persons 
bom  out  of  wedlock,  probably  because  women  bearing  bas- 
tards are  likely  themselves  to  be  degenerate.  That  public 
women  and  prostitutes  generally  are  in  large  percentage  sub- 
normal, and  that  many  others  who  lead  irregular  sexual  Hves 
are  likewise  to  be  classed  among  the  defectives,  needs  hardly 
to  be  pointed  out.  Again,  the  very  fact  of  the  bastard's 
anomalous  position  favors  the  attitude  of  mind  so  frequently 
seen  in  the  early  lives  of  paranoid  subjects.  Finally,  paranoia 
is  somewhat  more  frequent  among  the  unmarried,  among  those 
whose  lives  differ  from  the  rest  of  the  community  in  that  they 
are  denied  the  fulfilment  of  function  resulting  from  marriage 
and  parenthood.  The  traits  of  the  paranoid  subject  are 
such  as  frequently  not  to  favor  marriage,  and  the  fact  of 
living  alone  favors  the  evolution  of  the  paranoid  view  of  life. 
There  can  be  no  doubt,  however,  that  both  bastardy  and  celi- 
bacy are  factors  of  moment  only  in  the  lives  of  those  who 
are  predisposed;  i.  e.,  in  those  in  whose  nervous  make-up  the 
degeneration  leading  to  the  future  paranoia  is  inherent.  It  is 
sometimes  said  that  great  disappointments,  reverses,  neglect, 
wounded  pride,  unhappy  marriage,  play  a  role  in  the  etiology. 
Evidently  such  a  role  must  be  subsidiary  to  the  one  great  factor 
of  the  paranoid  predisposition. 

Paranoia  occurs  in  many  forms,  and,  as  already  pointed  out, 
these  can  be  roughly  grouped  under  two  heads:  first,  the 
common  hallucinatory  form,  and,  second,  the  non-halluci- 
natory form.  It  is  to  the  hallucinatory  form  that  we  will 
now  turn  our  attention. 

PARANOIA   HALLUCINATORIA 

Sjrmptomatology  and  Course. — The  common  or  hallucinatory 
form  of  paranoia,  though  presenting  itself  in  a  variety  of  ways, 
merits  the  following   general  description:    Because  of  the  ex- 


144  MENTAL    DISEASES 

tremely  gradual  appearance  of  the  symptoms  it  is  impossible 
to  fix  more  than  approximately  the  period  of  onset.  However, 
an  individual  who  has  previously  attracted  attention  as  being 
odd  and  eccentric,  or  who  has  been  observed  to  be  morbidly 
reserved,  reticent,  and  peculiar,  perhaps  suspicious  and  un- 
sociable, enters  upon  a  period  of  depression  and  of  hypochon- 
driasis. He  begins  to  suffer  from  various  obscure  visceral 
sensations.  These  appear  at  first  to  be  but  slightly  pronounced ; 
they  may  be  vague,  faint,  or  only  occasional  in  occurrence. 
Later  they  may  be  more  insistent,  unpleasant,  and  distressing. 
The  patient  refers  them  to  the  head,  the  body,  the  genitals. 
There  are  fulness  or  emptiness  of  the  head,  sensations  of  pres- 
sure or  constriction,  headache,  buzzing  in  the  ears,  distress  in 
the  praecordia,  palpitation,  unpleasant,  painful,  or  strange  sen- 
sations in  the  stomach  or  bowels,  or,  it  may  be,  throbbing  or 
other  queer  feelings  in  the  genitals.  These  sensations  are 
clearly  hallucinatory,  and  belong  to  the  group  of  the  visceral 
and  the  general  somatic  hallucinations.  The  patient  apparently 
suffers  from  these  hallucinations  for  a  long  time  before  he  speaks 
of  them.  Morbidly  reserved  and  suspicious,  he  is  apt  to  re- 
press the  impulse  to  complain  until  his  sufferings  become  in- 
sistent. Sooner  or  later  he  begins  to  seek  an  explanation  of  his 
troubles  in  causes  external  to  himself.  Sooner  or  later  he  comes 
to  believe  that  his  sufferings  have  been  imposed  on  him  from 
without.  Everything  that  he  hears  or  sees  begins  to  have  some 
relation  with  himself.  The  simplest  facts  acquire  a  special 
significance,  the  most  natural  happenings  have  a  sinister  mean- 
ing. Everything  about  him  is  changed.  People  look  at  him, 
whisper  about  him,  talk  about  him  as  he  passes.  Everything 
that  is  said,  everything  that  is  done,  has  a  special  significance 
for  him;  everything  is  interpreted  by  him  as  being  intended 
for  him.  People  dislike  him,  regard  him  with  aversion, 
threaten  him  with  harm.     Words,  tone  of  voice,  gestures  alike, 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  145 

are  inimical  and  insulting.  Little  by  little  the  patient  comes 
to  the  conclusion  that  he  has  long  been  an  object  of  animosity. 
The  most  trivial  events  of  the  past,  of  childhood  and  school,  of 
home  and  daily  life,  furnish  convincing  proof  that  his  interpre- 
tation is  correct. 

If  the  patient  be  studied  at  this  time,  it  will  be  found  that 
special  sense  hallucinations  have  also  made  their  appearance. 
In  the  great  majority  of  cases  they  are  of  hearing;  at  least, 
auditory  hallucinations  are  the  most  prominent.  Hallucina- 
tions of  vision  are  relatively  rare.  On  the  other  hand,  hallu- 
cinations of  smell  and  taste  are  not  infrequent,  and  this  is  also 
the  case  with  hallucinations  referred  to  the  general  body  sur- 
face and  to  the  genitals. 

The  hallucinations  of  hearing,  like  the  other  symptoms  pre- 
sented by  paranoia,  are  of  gradual  evolution.  Just  when  they 
begin  it  is  of  course  difficult  to  say.  Doubtless  in  some  cases 
they  begin  early  and  account  for  the  buzzing  and  other  dis- 
tressing sensations  of  which  patients  in  the  early  stage  of  the 
disease  complain,  though  these  sounds  may,  it  is  true,  at  times 
be  explained  as  ordinary  tinnitus.  However,  clinical  observa- 
tions show  that  the  sounds  first  heard  are  frequently  described 
by  the  patient  as  humming,  buzzing,  roaring,  or  are  compared  to 
the  ringing  of  bells;  sometimes  they  are  described  as  strange 
noises  or  as  sudden  explosions;  one  patient  described  them  as 
pistol  shots  and  interwove  them  with  his  delusions.  In  the 
well-developed  period  of  the  affection  the  auditory  hallucina- 
tions assume  the  form  of  words,  usually  of  vile,  profane,  obscene 
names,  of  curses,  reproaches,  threats.  That  the  patient  refers 
these  sounds  to  the  street,  to  the  open  window,  to  the  walls, 
to  the  ceiling,  is  but  natural.  Sometimes  short  phrases  are 
heard  and  these  constantly  repeated:  "kill  him,  kill  him," 
"serves  him  right,  serves  him  right."     Sometimes  in  this  con- 

10 


146  MENTAL    DISEASES 

dition  illusions  of  sound  pla}'  a  vivid  role,  as  when  the  ticking 
of  a  clock,  the  foot-falls  of  a  passing  stranger,  or  the  rattle  of  a 
wagon  constitute  a  recurring  tirade  of  curses  and  revilings. 

That  under  these  circumstances  delusions  also  are  present 
need  hardly  be  pointed  out.  At  first  the  patient  has  a  vague 
and  general  idea  that  his  sufferings,  his  tortures,  his  torments, 
are  caused  by  others;  "they,"  "people,"  are  annoying  him, 
persecuting  him.  Gradually  a  notion  of  conspiracy  is  evolved, 
"they"  have  conspired  to  injure,  to  poison,  to  electrify,  to  kill 
him.  Later,  or,  it  may  be,  in  some  cases  early,  a  certain  group 
of  persons  is  selected  as  constituting  the  conspiracy;  thus,  it 
may  be  the  relatives,  the  neighbors,  the  servants,  the  business 
associates,  or  it  may  be  a  special  organization,  religious  or  social, 
the  police,  or  the  government.  Sometimes  the  conspiracy 
includes  everybody,  and  everything  they  see  or  hear  is  directed 
against  them.  The  delusions  are,  as  has  already  been  pointed 
out  in  the  general  consideration  of  the  subject,  systematized. 
They  are  logical,  well  arranged,  and  well  coordinated. 

Quite  commonly  the  delusions  assume  specific  and  detailed 
features,  and  which  recur  in  various  patients  with  great  fre- 
quency. Thus  the  patient  believes  that  there  are  holes  in  the 
wall,  through  which  his  enemies  hurl  insults  and  curses,  or 
through  which  they  throw  poisonous  or  foul-smelling  vapors 
or  gases  or  other  harmful  substances.  Quite  frequentlj^  he 
believes  that  the  house  is  wired,  that  it  is  filled  with  speaking 
tubes,  that  everywhere  there  are  telephones,  that  the  telegraph 
wires  which  pass  his  window  convey  to  his  room  taunts,  vile 
names,  threats  from  his  enemies;  or  nowadaj's  it  may  be  the 
wireless,  electricity,  the  phonograph  of  which  his  enemies  make 
use.  The  hallucinations  may  become  more  detailed,  more 
vivid,  more  complicated.  The  patient  may  recognize  the  voice 
of  a  special  person,  or  it  may  be  that  he  clearly  distinguishes 
the  voices  of  several  persons  whom  he  knows.     At  other  times 


GROUP    III — THE    HEBOID-PARANOID   AFFECTIONS  147 

the  hallucinations  appear  as  an  echo  of  the  patient's  own 
thoughts;  the  latter  are  repeated  aloud  into  his  ears  as  fast  as 
they  are  formed.  It  may  be,  too,  that  the  patient  may  refer 
a  different  set  of  hallucinations  to  each  ear  respectively.  At 
other  times  the  patient  refers  the  voices  to  his  stomach,  to  his 
throat,  to  his  head,  or  to  some  other  part  of  his  body.  That 
he  may,  under  such  circumstances,  acquire  notions  of  double 
personaHty,  or  of  his  body  being  "possessed"  by  some  one  other 
than  himself,  can  be  readily  understood.  Sometimes  he  be- 
lieves that  some  one  other  than  himself  is  talking  through  his 
mouth,  and  he  may  even  move  his  lips  or  tongue,  as  in  the  act 
of  articulation,  though  not  uttering  any  sounds. 

General  somatic  and  visceral  hallucinations  which,  as  we 
have  seen,  are  in  the  beginning  vague,  and  give  rise  merely  to 
notions  of  illness,  to  hypochondriacal  ideas,  become  gradually 
better  defined  and  acquire  a  more  distinctly  objective  character. 
The  patient  feels  touches,  blows,  bums,  cramps,  spasms;  his 
flesh  is  pinched,  pierced,  electrified;  his  bowels  dragged  and 
twisted;  his  head,  his  eyes,  his  teeth,  wrenched,  seared,  torn. 
Especially  noteworthy,  too,  may  be  the  genital  hallucinations. 
Women  are  outraged,  painfully  abused,  their  genitals  torn  by 
instruments,  have  intercourse  night  and  day.  Men  are  mas- 
turbated, sodomized,  tortured,  castrated. 

Hallucinations  of  smell  and  taste  also  occur  with  great  fre- 
quency. The  patient  smells  disagreeable  odors,  foul  vapors, 
horrible  stenches.  These  come  .to  him  through  holes  in  the 
wall,  through  the  door,  the  window,  and  all  are  the  work  of  his 
enemies.  At  the  same  time,  his  tongue  is  the  seat  of  tastes 
strange,  disgusting,  vile,  and  horrible;  and  that  he  believes  his 
food  and  his  drink  to  be  poisoned  is  but  a  natural  sequence. 
Delusions  of  poisoning  are  exceedingly  common,  and  are  apt 
to  be  among  the  most  important  factors  determining  the  con- 
duct of  the  patient. 


148  MENTAL    DISEASES 

Hallucinations  of  vision  during  the  persecutory  period  of 
ordinary  paranoia  are  rare.  However,  they  may  occur,  and 
are  then  like  the  other  hallucinations  painful  and  distressing. 
The  patient  may  have  terrifying  visions;  he  may  see  gross, 
misshapen  figures  or  men  and  women  of  frightful  mien  and 
threatening  gesture.  Sometimes  it  is  especially  his  persecutor 
whom  he  sees.  One  of  my  patients,  a  man  of  some  education 
and  an  artist,  had  a  frequently  recurring  visual  hallucination 
which  he  called  the  "Opaluma."  It  was  a  female  figure  robed 
in  "opalescence,"  and  whenever  it  appeared  he  became  greatly 
excited  and  beheved  himself  to  be  in  great  danger.  Careful 
investigation  revealed  that  the  vision  was  that  of  a  female 
relative  who  frequently  wore  a  pink  dress  and  upon  whom  he 
had  centered  as  being  the  source  of  all  his  suffering.  In  order 
to  rid  himself  of  the  dreadful  presence  he  adopted  a  novel  ex- 
pedient. He  carried  with  him  a  bottle  containing  some  putre- 
fying organic  matter — apparently  a  decomposing  broth  or  soup 
with  particles  of  meat.  He  kept  it  tightly  corked,  but  when  the 
hallucination,  the  "Opaluma"  appeared,  he  would  quickly 
uncork  the  bottle,  press  it  to  his  nostrils,  and  take  repeated 
deep  inspirations.  Suddenly  he  would  look  up  and  say,  "Ah, 
she  doesn't  like  that!  She's  gone!"  The  bottle  was  certainly 
very  vile  and  foul-smelling,  and  it  is  not  impossible  that  the 
visual  hallucination  was  displaced  or  overwhelmed  by  the 
powerful  impression  made  upon  the  sense  of  smell. 

The  delusions  become  wdth  time  fixed  and  unchanging. 
Sometimes  the  patient  adopts,  as  in  the  case  just  cited,  a  new 
word,  sometunes  a  series  of  words,  the  origin  of  which  often 
caimot  be  traced.  This  symptom  is  but  a  part  of  the  general 
tendency  to  degeneration  and  fixation.  The  patient,  too,  lacks 
self-control  and  inhibition,  is  impulsive,  and  quick  to  take 
offence.  He  is  as  before  suspicious,  short  in  his  replies,  or  may 
decline  to  answer  questions  altogether,  saying,  "You  know  it 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  149 

already;"  he  seems  to  take  for  granted  that  the  voices  he  hears 
so  plainly  are  also  heard  by  his  questioner.  At  other  times  he 
is  seen  talking  to  himself,  frowning  and  gesticulating. 

The  patient  is  now  in  the  full  tide  of  his  persecution.  He 
may,  in  his  extremity,  complain  to  those  about  him,  his  friends 
or  neighbors.  He  may  write  letters  to  the  authorities,  to  the 
mayor,  to  the  police.  Not  infrequently  he  changes  his  resi- 
dence, moves  from  place  to  place  in  the  vain  attempt  to  escape 
from  his  persecutors.  Sometimes  he  appeals  to  the  courts. 
Not  infrequently  he  takes  the  law  into  his  own  hands.  That 
he  may  under  these  circumstances  become  exceedingly  danger- 
ous cannot  be  sufficiently  emphasized.  A  paranoiac  patient, 
hearing  a  sudden  sound  behind  him,  may  believe  himself  to  be 
insulted  and  may  turn  and  strike  a  blow;  or  the  hallucination 
may  give  rise  to  an  aggressive  impulse,  so  that  a  stranger  may 
be  assaulted.  However,  this  is  not  the  chief  source  of  danger. 
It  is  when  the  patient  has  settled  upon  some  one  person  or 
persons  as  constituting  his  enemies,  when  he  has  selected 
some  one  individual  who  is  the  cause,  mainspring,  and  origin 
of  his  troubles,  that  he  is  most  to  be  feared.  The  danger,  too, 
is  the  greater  because  the  unfortunate  victim  is  usually  in  igno- 
rance of  that  which  may  befall  him.  The  criminal  records  of 
every  city  unfortunately  furnish  repeated  instances  of  assault 
and  murder  on  the  part  of  delusional  lunatics.  The  victim 
being  selected,  the  patient  usually  makes  preparation  for  the 
act  which  he  believes  will  right  his  wrongs.  Usually  he  comes 
to  the  conclusion  that  there  is  nothing  else  to  do-;  not  only  will 
it  terminate  his  sufferings,  but  his  act  will  call  the  attention  of 
the  authorities  to  his  plight.  His  letters,  his  complaints  have 
met  with  no  response,  perhaps  with  jeers  and  laughter,  and  he 
must  end  it  all.  He  buys  a  revolver,  or  secures  some  other 
weapon,  and  lies  in  wait  for  his  victim.     One  paranoiac  rings 


150  MENTAL    DISEASES 

the  door-bell  and  insists  upon  the  person  he  is  seeking  coming 
to  the  door;  another  studies  the  movements  of  his  victim,  and 
traps  him  at  his  office  or  place  of  occupation;  a  third  waits 
until  he  catches  his  enemy  in  the  act  of  spreading  the  story  of 
his  shame  or  catches  his  wife  in  the  act  of  putting  poison  in  his 
tea.  Most  commonly,  in  the  medicolegal  experience  of  the 
writer,  the  murder  is  committed  by  a  firearm,  usually  a  revolver; 
much  less  frequently  by  cutting  instruments  or  other  means 
of  assault;  poisoning  is  rare;  the  same  is  true  also  of  arson. 
That  a  paranoiac  may  devise  original  and  unexpected  means 
of  killing  is  of  course  a  possibility. 

Premeditation,  curming,  foresight,  all  may  be  exhibited  by 
the  patient.  Usually  when  the  act  is  over  he  makes  no  at- 
tempt to  escape.  Quite  frequently  he  gives  himself  up  to  the 
authorities,  and  at  once  tells  all  about  his  troubles,  tells  all 
about  the  murder,  the  causes  that  led  to  it,  and  the  facts  that 
justified  it.  It  may,  indeed,  be  stated  as  a  general  truth  that 
the  act  is  open,  overt,  with  no  attempt  at  fiight  or  conceal- 
ment, and  that  it  is  quite  frequently  performed  in  a  dramatic 
manner,  as  though  to  call  attention  to  his,  the  patient's,  suffer- 
ings. 

The  persecutory  phase  continues  for  many  months,  more 
frequently  for  several  years,  when  certain  changes  are  observed 
both  in  the  delusions  and  in  the  demeanor  of  the  patient.  Little 
by  little,  though  sometimes  rapidly,  the  ideas  of  persecution 
are  replaced  by  ideas  of  expansion  and  the  patient  undergoes  a 
veritable  transformation  of  the  personality. 

In  the  very  beginning  of  the  persecutory  phase  we  note  that 
we  have  to  deal  with  a  personality  pathologically  expanded. 
Everybody  concerns  himself  about  the  patient,  the  newspapers 
write  about  him,  the  people  on  the  street  talk  about  him. 
Later  conspiracies  are  formed  against  him,  great  organizations, 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  151 

like  the  Masons,  powerful  bodies  of  men,  the  police,  the  de- 
tectives, combine  against  him.  It  is  not  surprising  that  in 
the  course  of  the  affection  the  patient  should  finally  arrive  at 
the  logical  conclusion  that  he  must  really  be  a  person  of  great 
consequence  to  be  the  object  of  such  great  and  insistent  effort 
to  effect  his  destruction.  In  reality  he  is  rich  and  powerful; 
he  is  not  the  poor  clerk  or  workman  he  is  given  out  to  be,  but 
he  is  really  of  aristocratic  rank  and  birth;  he  is  not  the  child 
of  the  persons  supposed  to  be  his  parents,  he  was  substituted 
in  the  cradle,  he  is  really  of  a  princely  line,  of  royal  descent,  an 
heir  to  a  throne  wrongfully  deprived  of  his  rights.  There  can 
be  no  doubt  that  in  some  patients  the  transition  to  the  expan- 
sive phase  is  accompanied  by  this  logical  train  of  ideas.  How- 
ever, in  the  form  of  paranoia  we  are  considering — that  is,  the 
hallucinatory  form — the  transformation  of  the  personality  is 
more  frequently  associated  with  the  appearance  of  pleasurable 
and  expansive  hallucinations.  Instead  of  curses,  vile  and 
obscene  names,  the  patient  now  hears  himself  addressed  in  words 
of  respect,  praise,  and  adulation;  wealth,  nobility,  titles  follow 
in  their  turn.  The  expansive  delusions  based  upon  them  com- 
monly lack  the  definiteness  and  precision  of  the  delusions  of  the 
stage  of  persecution;  indeed,  they  frequently  betray  by  their 
very  content  the  deterioration  attending  the  progress  of  the 
disease;  as  in  the  case  of  the  woman  patient  who  tells  us  that 
she  is  "queen  of  the  navy,"  or  of  the  man  who  insists  that  he  is 
"king,"  but  goes  no  farther,  and  is  content  to  wear  his  paper 
crown.  In  some  patients  the  transition  to  the  expansive  phase 
is  very  gradual,  and  during  this  period  both  persecutory  and 
expansive  hallucinations  may  exist  together,  at  times  one  and 
at  times  the  other  set  predominating. 


152  MENTAL    DISEASES 

THE   HYPOCHONDRIACAL   FORM 

The  picture  of  paranoia  outlined  above  is,  as  has  already  been 
indicated,  frequently  departed  from.  Not  only  are  there  pa- 
tients who  during  the  entire  period  in  which  they  are  under 
observation  remain  in  the  persecutory  phase — never  reaching 
the  period  of  transformation  and  expansion — so  there  are 
others  who  remain,  as  it  were,  in  the  preliminary  stage  of  hypo- 
chondriasis. In  such  instances,  hypochondriacal  ideas  domi- 
nate the  clinical  picture,  and  the  latter  may  resemble  an  ordi- 
nary hypochondriasis;  however,  the  paranoid  character  of  the 
symptoms  sooner  or  later  becomes  evident.  The  patient 
suffers,  as  before,  from  obscure  sensations,  unpleasant,  dis- 
tressing, or  painful,  which  he  refers  to  various  parts  of  his 
body  or  to  the  different  viscera.  It  is  early  noted  that  he 
pays  great  attention  to  the  passing  conditions  and  happenings 
in  the  external  world;  these  he  believes  influence  his  troubles 
or  perhaps  make  them  worse.  He  watches  the  wind,  the 
temperature,  the  dampness,  or  the  rain.  He  restricts  his 
diet  first  to  one  kind,  then  to  another  kind  of  foods;  he 
attributes  baneful  results  to  this  or  that  course  of  living,  to 
this  or  that  kind  of  medicine.  Sometimes  he  develops  ideas  of 
being  poisoned.  He  fails  to  get  reUef  from  a  physician  whom  he 
consults,  changes  to  another;  finally,  thinks  that  the  physicians 
are  harming  him,  and,  indeed,  doing  so  intentionally.  Perhaps 
it  is  some  other  person  to  whom  he  attributes  his  illness,  some 
one  who  is  hostile  to  him,  and  he  may,  as  in  ordinary  paranoia, 
evolve  a  series  of  systematized  persecutorj-^  delusions,  sometimes 
in  regard  to  a  group  of  persons,  sometimes  in  regard  to  one  per- 
son, as  in  paranoia  ordinarily. 

THE    SELF-ACCUSATORY    FORM 
Again,  cases  of  paranoia  are  met  with  in  which  the  patient 
may  manifest,   among   other  ideas,   ideas   of  self-accusation. 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  153 

These  cases  are  infrequent,  but  may  lead  to  confusion,  as  they 
bear  some  resemblance  to  melancholia.  The  patient  may 
say  that  he  is  very  wicked,  that  he  has  committed  this  or  that 
evil  deed,  has  been  dishonest,  has  committed  theft,  is  a  vile 
creature,  the  scum  of  humanity,  the  refuse  of  society.  How- 
ever, he  does  not,  as  in  melancholia,  talk  of  the  shame  and 
ruin  he  has  brought  on  his  family,  nor  does  he  evolve  the  delu- 
sion of  the  unpardonable  sin.  On  the  contrary,  the  very 
extent  of  his  self-accusation  implies  a  certain  expansion  of  his 
personahty.  Besides,  a  thread  of  persecution  may  run  con- 
currently with  the  ideas  of  self-accusation,  or  may,  while  the 
patient  is  under  observation,  become  frankly  established.  He 
is  deserving  of  punishment,  and  yet  finds  the  punishment  to 
which  he  is  being  subjected  out  of  all  proportion  to  his  faults; 
again,  he  says  that  he  is  not  responsible  for  the  things  that  he 
has  done,  that  he  was  led  to  do  them;  that,  indeed,  he  is  the 
victim  of  a  conspiracy  which  has  brought  about  the  situation 
in  which  he  finds  himself.  General  somatic  and  auditory  hallu- 
cinations, as  in  ordinary  paranoia,  may  also  play  a  role.  Every- 
thing convinces  him  that  he  has  always  been — indeed,  from  his 
very  birth — the  subject  of  e^al  influences,  the  victim  of  his 
enemies,  who  drove  him  into  evil  ways,  and  who  always  pre- 
vented him  from  doing  anything  good.  He  resents  the  injustice 
from  which  he  has  suffered,  and  httle  by  httle  the  ideas  of  self- 
accusation  disappear  and  are  replaced  by  ideas  of  persecution. 
Later  still,  and  in  due  course,  an  expansive  phase  may  follow,  the 
patient  believing  that  the  attention  which  has  been  directed  to 
him  from  all  sides  is  due  solely  to  his  importance,  that  just  be- 
cause of  his  prominence  he  has  been  selected  as  the  victim  of  the 
conspirators.  Paranoia  with  auto-accusations  is,  as  already 
stated,  infrequent,  if  not  rare.  Again,  the  picture  presented 
may   vary   at   different   times.     Auto-accusatory   and   perse- 


154  MENTAL    DISEASES 

cutory  ideas  may  be  present  at  the  same  time,  now  the  one 
and  then  the  other  group  being  more  prominent,  or  the  auto- 
accusatory  may  finally  give  way  altogether  to  the  persecutory 
ideas  while  the  patient  is  under  observation,  as  just  indicated 

above. 

THE   MYSTIC  FORM 

Much  more  interesting  than  either  the  hypochondriacal  or 
self-accusatory  forms  of  paranoia  is  the  form  to  which  the  term 
mystic  paranoia  has  been  applied.  Here  the  patient  again 
passes  through  a  hypochondriacal  period,  characterized  by 
vague  and  bizarre  sensations.  The  patient  may  as  before 
attribute  them  in  due  course  to  persecutory  agencies,  but 
sooner  or  later  they  receive  a  mystic  interpretation;  that 
is,  the  patient  believes  himself  either  to  be  the  victim  of  evil 
spirits,  demoniac  or  diabolical  agencies,  or,  perhaps,  that  his 
sufferings  have  been  inflicted  upon  him  in  accordance  with  the 
divine  will.  It  is  noted  that  patients  who  develop  mystic 
paranoia  frequently  present  in  their  childhood  abnormal  re- 
ligious tendencies;  thus,  they  dwell  upon  and  discuss  religious 
questions  to  a  morbid  degree,  devote  themselves  with  abnormal 
fervor  to  their  religious  duties,  make  premature  or  precocious 
religious  profession  or  manifest  phases  of  religious  exaltation. 
It  can  readily  be  understood,  also,  that  if  a  child  presenting 
such  peculiarities  be  in  addition  made  the  subject  of  undue 
religious  training,  or  be  brought  up  in  an  atmosphere  too 
austere  and  repressed,  an  atmosphere  in  which  the  depressing 
features  of  religious  doctrines  are  over-emphasized,  the  abnor- 
mal tendencies  of  the  child  may  become  greatly  exaggerated. 
However,  we  must  bear  in  mind  that  paranoiacs  are  born,  not 
made,  and  that  the  delusional  lunacy  from  which  they  suffer 
does  not  require  an  improper  religious  training  to  develop  it; 
the  latter  merely,  in  suitable  instances,  enhances  and  hastens 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  155 

the  development  of  the  sjonptoms.  In  many  cases  the  delusional 
state  observed  in  the  period  of  full  development  may  properly 
be  looked  upon  as  merely  an  outgrowth  or  amplification  of  the 
abnormal  traits  inherent  in  the  child. 

As  has  just  been  stated,  the  visceral  and  general  somatic 
hallucinations  of  the  depressive  period  are  ascribed  by  the 
patient  not  to  the  persons  about  him,  but  to  mysterious  and 
occult  causes.  He  is  being  persecuted  by  e\nl  spirits,  by 
sorcerers,  by  the  de\'il,  or  he  may  beheve  that  he  is  being  pun- 
ished by  God.  One  of  the  remarkable  facts  of  mystic  paranoia 
is  the  great  frequency  and  prominence  of  sexual  phenomena. 
These  doubtless  have  their  birth  in  genital  hallucinations; 
of  all  the  visceral  hallucinations  these  lead  to  the  most  striking 
results.  The  patient  is  erotic;  sexual  excitement  is  marked; 
he  gives  way  to  masturbation,  practices  sexual  congress,  sexual 
excess,  perhaps  sexual  perversion.  Every  sexual  act  is  pre- 
ceded by  painful  struggles  and  followed  by  remorse  and  dis- 
couragement. Sometimes  the  patient's  eroticism  is  purely 
mystic ;  he  or  she  is  in  love  with  this  or  that  saint,  this  or  that 
divine  personage.  Women  are  subjected  to  carnal  temptation 
by  the  Godhead  to  test  their  virtue,  or  they  claim  intercourse 
with  the  Deity,  are  pregnant,  and  vnll  give  birth  to  the  Sa\dour. 
,  The  sexual  hallucinations  seem  m  some  cases  to  be  very  \dvid 
and  to  be  accompanied  by  very  active  sensations. 

Sooner  or  later  \asual  hallucinations  are  added.  Indeed,  it 
is  characteristic  of  mystic  paranoia  that  visual  hallucinations, 
hke  the  sexual  hallucinations,  are  very  frequent  and  promment. 
The  patient  who  is  absorbed  in  his  excessive  piety  becomes 
more  and  more  intense  in  his  devotion,  spends  his  time  almost 
continuously  in  religious  contemplation  and  prayer,  and  finally 
begins  to  hold  communication  vnth  God,  the  Saviour,  the 
Virgin,  the  angels,  who  appear  to  him  in  \dsions.     The  hallu- 


156  MENTAL    DISEASES 

cinations  may  consist  of  bright  lights,  brilliant  halos,  glorious 
and  imposing  figures,  who  smile  upon  him,  make  signs  and  ges- 
tures. Usually  the  patient  tells  us  of  the  things  he  sees;  later, 
in  many  eases,  it  is  evident  that  the  visions  also  speak  to  him. 
In  other  words,  in  the  progressive  development  of  symptoms 
hallucinations  of  hearing  are  added,  and  the  voices  tell  him  of 
the  great  mission,  the  great  future  that  is  his;  he  is  destined 
to  save  the  world,  to  reform  mankind,  he  is  to  be  the  Messiah, 
is  to  represent  God  on  earth.  The  expansion  grows  until  he 
not  infrequently  asserts  that  he  is  "the  Christ"  or  God  himself 
come  back  to  earth.  During  the  seeing  of  the  apparition  and 
the  hearing  of  the  voices,  the  patient  may  pass  into  a  clearly 
marked  hysterical  crisis.  He  may  pass  into  a  condition  of  ec- 
stasy, and  not  infrequently  he  assumes  fixed  or  cataleptic 
attitudes. 

In  mystic  paranoia,  as  in  the  other  forms,  the  patient  passes 
through  a  period  of  depression,  a  transformation,  and  a  period 
of  expansion.  The  patient  looks  upon  his  period  of  depression, 
w^th  its  trials  and  sufferings,  as  a  period  of  probation,  during 
which  he  is  tested,  chastened,  prepared  for  the  great  role  to 
follow.  The  period  of  depression  is  commonly  quite  prolonged, 
the  ideas  are  evolved  gradually  and  slowly  systematized. 
Sometimes  the  transition  to  the  expansive  stage  is  very  gradual, 
so  that  both  persecutory  and  expansive  ideas  may  be  present 
at  the  same  time.  Thus,  while  the  patient  believes  himself 
to  be  ordained,  and  is  actually  engaged  in  carrying  out  the 
divine  will,  he  is,  notwithstanding,  suffering  from  the  evil  in- 
fluences about  him,  is  subjected  to  carnal  and  other  tempta- 
tions by  the  devil. 

Quite  commonly  the  mental  state  of  the  mystic  paranoiac 
is  such  that  his  pathologic  condition  is  readily  recognized. 
Sometimes,  however,  he  is  a  man  or  woman  of  powerful  per- 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  157 

sonality,  of  force,  of  natural  eloquence,  and  of  convincing 
manner.  Under  such  circumstances,  he  not  infrequently 
secures  a  following,  and  one,  too,  that  may  grow  to  huge  pro- 
portions. One  need  hardly  mention  the  divine  healers  who 
arise  in  every  age  and  in  every  country,  nor  speak  of  those  who 
actually  found  new  faiths  and  creeds.  Mystic  paranoia  is  a 
danger  that  is  real,  grave,  insidious.  The  unknown,  the  mys- 
terious, the  occult  inspire  awe  and  dread;  they  also  weave  a 
hypnotic  spell;  they  bind  in  hopeless  impotence,  chain  in 
blind  fascination  the  simplest  workings  of  the  mind.  The 
every-day  facts  of  life,  of  existence,  are  denied  and  absurd 
delusions  substituted.  Realities  are  hallucinated  away  and 
replaced  by  the  intangible  figments  of  mental  disease.  The 
communicated  madness  so  arising  may  become  epidemic  and 
may  last  for  centuries.  The  r61e  played  by  the  mystic  para- 
noiac is  well  illustrated  by  the  history  of  Sabbatai  Sebi,  so 
dramatically  told  by  Zangwill  in  his  "Dreamers  of  the  Ghetto." 
Sabbatai,  a  typical  mystic,  after  a  long  preliminary  period  of 
depression  and  preparation,  passed  through  a  typical  transfor- 
mation, and  finally  announced  himself  as  the  Messiah.  He 
performed  miracles,  was  accepted  by  many  thousands  of  Jews, 
and  even  by  Gentiles,  both  in  Palestine  and  Europe,  and  even 
after  the  collapse  of  his  pretensions  and  his  death  a  sect,  the 
"Dormeh"  of  Salonica,  long  survived  him. 

Mystic  paranoiacs  are  not  physically  as  dangerous  as  the 
ordinary  persecutory  cases,  and  yet  their  delusions  some- 
times lead  them  to  the  performance  of  barbarous  and  cruel 
acts.  Now  and  then  a  mystic  will,  in  obedience  to  his  hal- 
lucinations, slay  his  own  child — perhaps  as  a  sacrificial  offer- 
ing or  in  order  to  hasten  its  advent  into  paradise.  Others 
during  the  period  of  depression  and  suffering,  a  period  often 
regarded  by  them  as  one  of  penance,  will  scourge  themselves 


158  MENTAL    DISEASES 

or  subject  their  bodies  to  self-inflicted  torture.  The  patient 
believes  that  these  punishments  chasten  him  and  are  pleasing 
to  God;  he  often  regards  them  as  his  only  means  of  sal- 
vation. Sometimes  he  mutilates  his  own  body;  thus,  the 
Skoptzi,  a  mystic  sect  of  Russia,  castrate  themselves  and 
amputate  the  breasts  of  their  women.  Others  again  see  in 
death,  in  suicide,  the  only  hope  Sometimes  a  mystic  will 
persuade  others  to  join  him,  and  a  number  of  persons  may  agree 
to  die  together  and  may  actually  carry  out  their  project.  The 
method  selected  may  be  extremely  barbarous  and  revolting. 
Thus,  the  patients  may  bury  or  immure  themselves  alive.  Not 
longer  ago  than  1897  an  incident  of  this  kind  occurred  at 
Temovo,  Russia.  A  community  of  "old  believers"  objected 
to  the  taking  of  the  census,  a  proceeding  which  they  regarded 
as  sacrilegious;  rather  than  submit  to  this  persecution,  and 
led  by  one  of  their  fanatics,  they  decided  to  die.  They  dug 
their  own  graves,  which  they  entered  alive,  while  one  of  their 
number,  who  had  been  charged  with  this  duty,  filled  the  graves 
with  earth  and  stones.  Twenty-five  persons  actually  perished 
in  this  way.  The  member  who  survived,  and  who  carried  to 
its  fulfilment  this  terrible  act,  failed  to  keep  his  own  promise, 
for  he  lacked  the  courage  to  kill  himself.  Only  a  few  years 
ago  an  incident  occurred  in  Canada  that  was  almost  as  dis- 
tressing and  certainly  infinitely  pathetic.  Members  of  a  Russian 
colony,  composed  of  a  rehgious  sect  known  as  the  Doukhobors, 
under  the  leadership  of  one  of  their  number,  wandered  over  ice 
and  snow,  barefooted  and  bleeding,  faint  and  famishing,  seeking 
Christ  in  the  wilderness.  They  knew  that  Christ  was  there, 
that  they  would  see  Him  in  the  flesh,  hear  His  voice,  and  that 
all  their  sufferings  would  be  at  an  end.  The  Canadian  Gov- 
ernment was  finally  obliged  to  intervene,  and  to  arrest  this  cruel 
and  aimless  pilgrimage  by  force.    It  must  not  be  imagined  that 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  159 

incidents  of  this  kind  occur  only  among  Russian  peasants; 
nor  must  we  go  back  to  the  Middle  Ages  or  to  European  coun- 
tries to  find  examples  of  the  baneful  influences  of  mystic  para- 
noia. It  is  not  necessary  to  go  back  even  as  far  as  our  own 
Salem  witchcraft  to  meet  \Nath  incidents  equally  terrible.  In 
our  own  country,  in  our  own  day,  with  its  boasted  enlighten- 
ment and  civilization,  a  woman  is  allowed  to  die  in  childbirth, 
a  child  of  diphtheria,  a  man  to  lose  his  eyesight,  a  contagious 
disease  to  become  epidemic,  all  because  the  relatives  and  friends 
of  the  patient  are  followers  of  a  cult  which  denies  the  very 
existence  of  disease. 

It  is  one  of  the  unfortunate  peculiarities  of  mystic  paranoia 
that  it  frequently  and  very  readily  spreads,  as  we  have  seen,  to 
other  persons.  Unfortunately  every  community,  and  especially 
the  modern  community,  contains  large  numbers  of  persons 
of  feeble  mental  resistance,  of  hysterical  make-up,  of  persons 
who  are  morbidly  vulnerable  to  suggestion.  It  is  these  upon 
whom  the  delusions  are  grafted,  and  it  is  they  who  in  turn 
transmit  them  to  others.  It  is  interesting  to  note,  also,  that 
the  hallucinations  of  vision  and  hearing  are  excited  in  a  rela- 
tively small  number;  it  is  the  naked  delusions  that  are  taken 
up  by  the  masses.  Ordinary  persecutory  paranoia  may  also, 
though  rarely,  be  communicated  to  others;  this  may  occur  in 
hallucinatory  paranoia,  though  it  is  more  likely  to  occur  in  the 
non-hallucinatory  form.  This  conununicated  madness  will 
be  considered  a  little  later.  (See  Part  II,  Chapter  IV.)  At 
present,  we  will  turn  our  attention  to  the  non-hallucinatory 
form  of  paranoia  or  paranoia  simplex. 

PARANOIA  SIMPLEX 

The  term  paranoia  simplex  is  here  used  to  designate  a  sys- 
tematized delusional  lunacy,  in  which  the  delusions  are  related 


160  MENTAL    DISEASES 

to  the  perceptions  of  the  patient  rather  than  to  any  hallucina- 
tions which  he  may  have.  He  weaves  his  delusions  from  the 
things  he  actually  hears  and  sees.  Hallucinations  are  here 
less  prominent  and  play  a  less  striking  role  than  in  ordinary 
hallucinatory  paranoia.  However,  that  the  patient  is  not 
suffering  merely  or  even  principally  from  a  defect  of  his  logical 
faculty  becomes  evident,  I  think,  when  we  carefully  study  him. 
We  soon  learn  that  the  delusive  ideas,  even  though  not  the  out- 
growth of  special  sense  hallucinations,  are  intimately  asso- 
ciated with  disturbances  in  the  way  the  patient  feels;  i.  e.,  with 
disturbances  of  his  general  somatic  feelings  or  sensations. 
These  disturbances  should,  I  beheve,  be  regarded  as  hallu- 
cinatory, just  as  much  as  special  sense  or  visceral  hallucina- 
tions. Further,  when  w'e  learn  that  in  some  cases  frank  and 
outspoken  hallucinations  of  the  special  senses  are  also  present, 
we  conclude  justly  that  the  difference  between  this  and  the 
ordinary  hallucinatory  form  is  not  as  great  as  would  at  first 
sight  appear.  However,  this  form  presents  certain  striking 
peculiarities;  first,  although  the  patient  evolves  a  series  of 
systematized  and  fixed  delusions,  there  is,  at  the  same  time,  a 
remarkably  high  preservation  of  the  general  lucidity,  of  the 
ordinary  sequence  of  thought,  of  ordinary  conduct  and  will- 
power; second,  the  course  of  the  disease  is  excessively  slow — 
so  slow  that,  though  the  tendency  is  as  in  ordinary  paranoia 
toward  mental  deterioration,  such  deterioration  may  not  be 
marked  even  after  the  patient  has  been  under  observation  for 
many  years.  It  was  such  considerations  as  these  which  led 
Kraepelin  to  grant  this  affection  an  entirely  separate,  a  distinct, 
consideration  in  his  nosology,  departing,  in  this  respect,  from 
his  earlier  position,  in  which  he  treated  it  as  in  close  coimection 
with  ordinary  hallucinatory  paranoia.  In  taking  this  course 
the  distinguished  German  aUenist  has,  I  believe,  done  violence 
to  clinical  fact.    He  has  accepted  merely  differences  of  degree 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  161 

as  radical  distinctions,  and  has  not  given  due  weight  to  inter- 
mediate forms,  the  existence  of  which  must  be  frankly  admitted. 
After  all,  the  discussion  resolves  itself  into  the  question  of  the 
use  and  application  of  the  word  paranoia,  and  to  me  it  seems, 
as  already  stated,  that  the  purposes  of  psychiatry  and  of  the 
student  are  best  served  by  retaining  the  word  in  the  sense  in 
which  Mendel  first  employed  it. 

The  beginning  of  the  affection  is  extremely  gradual.  It  is 
characterized  by  depression,  which  may  be  slight  in  character, 
by  obscure  bodily  ills,  by  vaguely  defined  hypochondriacal  or 
visceral  sensations.  At  times  the  latter  attain  the  character 
of  well-defined  hallucinations.  The  depression  may  be  suffi- 
ciently marked  to  attract  the  attention  of  the  family;  more  fre- 
quently it  is  fugitive,  changing,  recurring;  perhaps  accompanied 
by  ill-defined  fears  or  suspicions.  One  of  my  patients,  while  in 
this  stage,  retreated  to  his  home  in  the  country,  isolated  himself 
for  months,  and  denied  himself  alike  to  friends  and  relatives. 
The  latter  became  alarmed  and  declared  that  he  must  be  ill,  a 
fact  which  he  indignantly  denied,  and  at  once  attributed  to  their 
desire  for  his  death  that  they  might  profit  by  his  estate. 

Sooner  or  later  the  patient  acquires  the  notion  that  he  is 
not  being  properly  treated  by  his  family.  He  feels  that  he  is 
being  ignored,  is  not  receiving  the  attention  which  is  his  due; 
no  one  understands,  no  one  appreciates  him.  He  develops  a 
growing  feeling  of  antagonism  to  those  about  him;  conducts 
himself  like  a  stranger;  is  indifferent,  unnatural,  even  inimical. 
Little  by  little  his  distrust  of  those  about  him  steadily  increases. 
A  word,  a  phrase,  a  harmless  remark  is  taken  up,  brooded  over 
and  misinterpreted.  A  smile,  a  glance,  a  cough  is  regarded  as 
a  covert  sign,  an  expression  of  derision  or  of  hatred.  Every- 
thing that  he  sees  or  hears  now  adds  fuel  to  the  flame.     Articles 

in  the  daily  paper,  actors  upon  the  stage,  the  whistling  of  a 
11 


162  MENTAL   DISEASES 

popular  air  upon  the  street,  all  have  a  peculiar  significance; 
all  are  intended  for  hiin.  He  is  being  lied  about,  libeled, 
traduced,  vilified,  calumniated.  At  first  reticent,  he  may  later 
accuse  persons  about  him  of  wilfully  and  purposely  maligning 
and  trying  to  ruin  hmi.  He  looks  upon  their  astonishment  as 
assumed,  and  upon  their  disclaimers  as  mere  evasions  of  the 
truth.  Sooner  or  later  he  becomes  convinced  of  the  formation 
of  a  conspiracy  against  him.  Sometimes  this  conspiracy  as- 
sumes huge  proportions,  and  may  include  even  the  crowned 
heads  of  the  world.  At  the  same  time,  he  develops  ideas  of 
grandeur.  He  discovers  new  and  wonderful  qualities  in  him- 
self; he  feels  that  he  is  very  talented,  very  learned,  a  great  poet, 
a  great  composer;  is  on  the  eve  of  making  great  discoveries 
which  he  will  with  great  magnanimity  give  to  the  world.  One 
of  the  patients  under  my  observation  boasted  of  having 
written  many  hundreds  of  poems  and  exhibited  a  large  num- 
ber of  doggerel  rhymes.  Another  made  a  great  mathematical 
discovery, — namely,  that  numbers  have  sex;  another  still  dis- 
covered that  his  right  hand  communicated  to  him  in  auto- 
matic writing  the  manner  in  w^hich  he  was  to  conduct  his 
business  with  success.  (See  Part  III,  Chapter  I.)  The  same 
patient  believed  that  a  huge  conspiracy  had  been  formed 
against  him  to  obtain  possession  of  his  wealth. 

As  in  ordinary  paranoia,  the  very  magnitude  of  the  con- 
spiracy against  the  patient  proves  that  he  is  in  reality  a  great 
personage.  Long  dissatisfied  with  his  surroundings,  wdth  the 
circumstances  in  which  he  has  been  born,  he  now  denies  his 
parentage.  The  reputed  parents  are  not  his;  they  suddenly 
stop  speaking  when  he  enters  the  room,  or  speak  in  whispers; 
are  frightened,  look  guilty  when  he  addresses  them.  They  have 
merely  been  the  paid  agents  of  his  enemies  to  keep  him  in  ob- 
scurity.    To  accentuate  the  difference  between  himself  and 


GROUP   III — THE   HEBOID-PARANOID   AFFECTIONS  163 

his  family,  he  may  change,  as  did  one  patient,  the  spelhng  of 
his  name;  another  added  a  new  name  to  the  one  she  already 
bore  and  changed  her  nationality.  Another  still  deliberately 
changed  both  her  name  and  her  mother. 

The  fact  that  the  patient  is  really  an  important  and  powerful 
personage  is  strengthened  by  the  evidence  which  he  sees  every- 
where about  him.  Distinguished  people,  people  of  wealth, 
men  of  affairs,  the  nobility,  princes,  royalty,  go  out  of  their  way 
to  meet  him,  if  only  to  pass  him  in  their  carriages.  He  fancies 
that  great  riches  await  him,  riches  of  which  he  has  been  un- 
justly deprived;  or,  he  is  a  great  reformer,  is  to  become  Pope, 
has  a  mission  to  perform,  may  believe  himself  to  be  the  Mes- 
siah. He  may  also  dress  himself  in  some  peculiar  way  in  keep- 
ing with  his  expansive  state.  His  hair  or  his  beard  may  be 
worn  excessively  long  or  may  be  peculiar  in  their  cut.  How- 
ever, it  is  rather  his  manner,  his  demeanor,  and  gestures  that 
attract  attention. 

The  patients  suffering  from  this  form  of  paranoia  commonly 
present  a  commingling  of  persecutory  and  expansive  ideas. 
In  the  beginning  there  is  present  a  depression,  a  persecutory 
phase;  relatively  early,  however,  expansive  ideas  manifest 
themselves,  and  there  is  not  that  definite  period  of  the  trans- 
formation of  the  personality  so  often  seen  in  typical  hallucina- 
tory paranoia.  Further,  when  the  patient  is  well  launched 
into  the  expansive  phase  the  persecutory  ideas  are  usually  nibt 
forgotten,  but  frequently  persist  in  a  marked  degree;  after  all, 
however,  the  expansive  ideas  are  much  niore  pronounced  than 
the  depressive;  the  latter  seem  merely  to  stimulate  and  ac- 
centuate the  expansion.  The  expansion  at  times  assumes 
almost  incredible  proportions.  Thus,  in  one  patient,  a  woman, 
the  conspiracy  embraced  her  mother,  her  sister,  her  neighbors, 
prominent  citizens  of  her  city,  merchants,  the  editors  of  news- 


164  MENTAL   DISEASES 

papers,  the  mayor,  the  governor,  national  senators,  the  presi- 
dent of  the  United  States,  the  king  and  queen  of  England,  the 
president  of  France,  the  emperor  of  Germany,  the  Pope.  All 
of  these  persons  were  united  in  one  vast  conspiracy  to  injure 
and  destroy  her,  to  poison  her,  to  do  her  to  death.  The  object 
of  this  huge  plot  was  to  secure  possession  of  a  vast  fortune 
which  she  possessed.  She  believed  herself  to  be  a  person  of 
great  consequence  and  influence;  she  possessed  greater  power 
than  the  Pope.  To  show  how  slender  is  the  basis  of  fact 
on  which  a  paranoia  of  this  kind  is  based  it  should  be  stated 
that  a  distant  relative  had  died  about  fifty  years  before,  in 
some  unknown  part  of  the  world,  and  the  tradition  survived 
him  that  he  had  left  an  estate.  Not  a  scrap  of  paper,  not 
a  letter,  not  a  single  writing,  not  a  vestige  of  any  evidence, 
written  or  oral,  of  the  actual  existence  of  this  estate  existed, 
and  yet  upon  a  mythical  tradition  the  patient  built  her  vast 
superstructure  of  illimitable  powder,  wealth,  and  world-wide 
conspiracy.  Ordinarily  this  form  of  paranoia  is  defined  as 
one  in  which  the  patient  evolves  his  delusions  from  actual 
experiences,  actual  observations  and  perceptions;  how  little 
semblance  of  actual  fact  may  suffice  the  case  just  cited  fully 
illustrates.  Evidently,  too,  we  cannot  ascribe  the  delusions 
altogether,  or  even  in  large  part,  to  the  tradition  of  a  wealthy 
relative;  they  must  have  had  some  other  basis,  some  other 
mainspring  of  origin.  This,  it  seems  to  me,  can  only  be  found 
in  the  "feeling"  of  the  patient.  The  "feeling"  of  greatness 
and  power  must  be  looked  upon  as  a  hallucination,  a  hal- 
lucination of  [the  cenesthesis,  or,  better  still,  of  the  general 
psychosomatic  sense.  We  know  that  certain  poisons,  e.  g., 
alcohol,  induce  such  hallucinations  of  "feeling,"  and  it  does 
no  violence  to  suppose  that  the  pleasurable  states  of  para- 
noia are  similarly  hallucinatory,  and,  it  may  be,  similarly  of 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  165 

toxic  origin.  That  hallucinations  of  taste  occur  in  this  form 
of  paranoia  can  be  inferred  from  the  frequent  presence  of  the 
delusion  of  poisoning.  Hallucinations  of  hearing  are  infre- 
quent, but  they  also  are  met  with.  This  is  true  also  of  hal- 
lucinations of  sight. 

The  difference  between  this  form  of  paranoia  and  ordinary- 
hallucinatory  paranoia  is  not  quite  as  great  as  it  would  seem. 
In  the  latter  the  delusions  are,  as  has  been  pointed  out,  inti- 
mately associated  with  hallucinations — visceral,  auditory,  and 
at  times  visual;  in  the  form  under  discussion,  the  persecutory 
and  expansive  ideas  are  likewise  associated  with  hallucinations, 
with  hallucinatory  states  of  the  general  body  sense,  and,  though 
in  a  much  less  marked  degree,  with  ordinary  visceral  and  special 
sense  hallucinations. 

A  final  point  remains  to  be  again  emphasized;  namely,  the 
relatively  high  degree  of  lucidity  in  paranoia  simplex.  This 
lucidity  is  so  great  that  persons  coming  into  casual  contact  with 
the  patient  may  not  suspect  that  he  is  insane.  It  is  only  when 
the  well-spring  of  delusions  is  tapped  that  the  condition  of  the 
patient  becomes  evident,  or  when  some  overt  or  unusual  act 
attracts  attention.  Because  of  this  relatively  high  lucidity, 
it  is  often  extremely  difficult  and  even  hazardous  to  bring  about 
.  the  commitment  of  the  patient  to  an  asylum.  Not  infrequently 
there  are  relatives,  bearing  the  stripe  of  the  same  disease,  or 
who  have  more  or  less  adopted  the  patient's  delusions  by  con- 
tagion (see  Part  II,  Chapter  IV),  who  stoutly  resist  commit- 
ment; again,  the  patient,  having  been  committed,  employs 
attorneys  to  secure  his  release,  and  may  thus  give  relatives, 
physicians,  and  friends  endless  trouble.  The  patient  himself 
is  so  clear  that  he  fully  recognizes  the  nature  of  the  legal  pro- 
ceedings instituted  to  regain  his  liberty;  he  regards  his  com- 
mitment as  merely  an  evidence  of  the  conspiracy  against  him 


166  MENTAL   DISEASES 

and  decides  to  oppose  cunning  with  cunning.  In  other  words, 
he  suppresses  his  delusions,  declares  that  he  has  no  enemies, 
does  not  believe  that  he  is  the  peer  of  emperors,  kings,  and 
popes.  When  confronted  with  letters  and  other  evidences  of 
his  delusions  in  his  o^vn  handwriting  he  may  answer,  "Yes,  I 
did  think  like  that  at  one  time,  but  I  know  now  that  that  is 
not  so;  I  don't  think  so  now."  There  is  a  limit  of  course  to 
this  suppression  of  delusions.  Sooner  or  later  they  come  to 
the  surface  again;  sooner  or  later  a  skilful  question,  an  un- 
expected thrust,  will  reveal  the  truth;  and  yet  the  patient 
may  simulate  the  absence  of  the  delusions  so  successfully  as 
to  deceive  physicians,  court,  and  jury.  Finally,  asylums 
and  physicians  dislike  litigation  extremely,  and  are  anxious 
to  get  rid  of  these  very  troublesome  cases.  As  a  result, 
the  number  of  cases  of  paranoia  simplex  found  in  any  one  in- 
stitution is  extremely  small;  sometimes,  indeed,  there  is  none. 
Occasionally  this  form  of  paranoia  presents  itself  with  special 
clinical  features.  Thus,  as  in  ordinary  paranoia,  erotic  symp- 
toms are  very  common.  The  patient,  if  a  woman,  frequently 
claims  to  have  received  offers  of  marriage  from  distinguished 
personages;  at  other  times  she  is  the  victim  of  indecent  pro- 
posals, or  she  may  give  herself  up  to  obscene,  filthy,  vile  accusa- 
tions against  others.  Every  now  and  then  sexual  ideas  dominate 
the  entire  picture.  This,  for  instance,  was  the  case  in  a  patient 
who  made  the  discovery  that  the  sexual  organs  in  both  man 
and  woman  consisted  of  two  entirely  separate  parts;  namely, 
certain  structures  which  she  termed  the  "love  organs,"  and 
certain  stnictm-es  which  she  termed  the  "reproductive  organs." 
She  further  declared  that  she  had  discovered  a  method  by  means 
of  which  the  love  organs  alone  could  exercise  their  function 
without  the  reproductive  organs  taking  any  part;  in  other 
words,  she  claimed  to  have  knowledge  of  a  method  by  means 
of  which  the  sexual  act  could  be  prolonged  and  repeated  in- 


GROUP   ni — THE   HEBOID-PARANOID   AFFECTIONS  167 

definitely  without  any  risk  of  impregnation.  She  called  this 
state  the  perpetual  honeymoon.  Although  she  was  unmar- 
ried, and,  as  far  as  could  be  ascertained,  had  herself  never 
had  carnal  knowledge,  she  conceived  it  to  be  her  mission  to 
instruct  mankind  in  her  discoveries.  This  she  advertised  to 
do  by  private  instruction,  for  which  she  proposed  to  charge  a 
fixed  fee,  and  she  also  wrote  and  had  printed  pamphlets  which 
she  disseminated  in  various  ways.  Later,  sexual  hallucina- 
tions seem  to  have  become  very  vivid,  and  led  in  due  course 
to  the  delusion  that  she  had  a  ''spirit  husband."  At  various 
times  the  sending  of  her  pamphlets  through  the  mails  brought 
her  into  conflict  with  the  postal  authorities,  and  upon  one 
such  occasion  she  was,  after  medical  examination,  committed 
to  an  asylum.  She  presented  such  a  high  degree  of  lucidity 
that  the  hospital  authorities  contemplated  her  discharge, 
when  she  was  transferred  to  another  institution.  Here  she 
remained  a  number  of  months,  when  she  finally  secured  her 
release  by  disavowing,  first,  her  belief  in  her  spirit  husband, 
and,  finally,  her  other  delusions.  After  her  release  she  removed 
to  another  city,  again  announced  her  views,  again  violated  the 
law  relating  to  the  sending  of  indecent  matter  through  the  mails, 
was  arrested,  and,  finally,  killed  herself  by  the  inhalation  of 
illuminating  gas. 

More  frequently  the  eroticism  manifests  itself  in  other  ways. 
Sometimes  the  patient,  no  doubt  as  an  outgrowth  of  her  sexual 
hallucinations,  believes  that  there  is  a  conspiracy  to  defame  her 
character,  to  impugn  her  virtue;  at  others  she  makes  accusa- 
tions of  indecent  proposals,  exposure  of  the  person,  rape, 
assaults  of  all  kinds.  Again,  a  chance  meeting,  a  glance  in 
the  patient's  direction,  a  phrase  upon  the  stage,  a  few  lines  in 
a  newspaper,  convince  the  patient  that  this  or  that  prominent 
person  is  in  love  with  her.  Thus,  one  patient  beheved  that 
a  President,  with  whom  she  had  never  exchanged  a  word,  and 


168  MENTAL    DISEASES 

who  already  had  a  wife,  was  anxious  to  marry  her.  Occa- 
sionally such  patients  write  amorous  letters  and  in  other  ways 
subject  the  object  of  their  delusions  to  annoyance  and  even 
persecution.  If  answers  are  not  received,  the  patient  writes 
again — usually  many  times — and,  still  receiving  no  response, 
sooner  or  later  enters  upon  a  campaign  of  threats,  of  reprisals, 
vilification,  and  abuse.  Not  infrequently,  the  patient  is  an  old 
maid  and  near  or  at  the  menopause;  perhaps,  she  is  in  the  early 
forties.    (See  Part  III,  Chapter  I.) 

At  times,  again,  paranoia  assumes  the  form  of  an  insane 
jealousy  of  the  wife,  husband,  or  loved  one.  That  much  suffer- 
ing may  thus  ensue  to  the  unfortunate  object  goes  without 
saying.  The  latter  is  watched,  spied  upon;  every  act,  every 
innocent  word  is  woven  into  the  delusions.  The  husband 
believes  that  everybody  is  trying  to  seduce  his  wife;  she  cannot 
move  about,  speak  to,  or  permit  herself  to  be  in  the  com- 
pany of  the  opposite  sex.  Accusations,  cruelty,  persecution, 
sometimes  assaults,  and  even  murder  may  occur  under  these 
circumstances.  As  we  shall  see  a  little  later,  the  delusions  may 
assume  the  character  of  clearly-marked  belief  of  marital  in- 
fidelity, especially  in  the  so-called  alcohohc  form  of  paranoia. 
(See  Part  II,  Chapter  I.) 

Sometimes  the  delusions  assume  a  political  character.  The 
patient  believes  that  he  is  being  watched,  that  spies  are  upon 
his  track,  that  information  is  being  lodged  against  him,  that 
he  is  in  danger  of  arrest  and  imprisonment;  that  the  govern- 
ment is  persecuting  him.  Of  course  the  expansive  delusions, 
that  he  is  an  important  political  personality,  that  he  has  been 
rightly  elected  to  this  or  that  office,  of  which  he  is  deprived  by 
the  machinations  of  his  enemies,  are  not  wanting,  and  that  they 
may  assume  most  varied  forms  goes  without  saying.  Again 
he  is  the  heir  deprived  of  his  heritage,  the  rightful  ruler,  the 
victim  of  political  conspirators. 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  169 

Every  now  and  then  the  affection  assumes  the  form  of  a 
paranoia  of  Htigation.  The  patient  beheves  that  he  can  only 
obtain  redress  for  his  wrongs  in  the  courts.  He  brings  suit,  it 
may  be,  because  he  believes  himself  to  have  been  unjustly 
treated  by  the  executors  of  an  estate,  defrauded  of  his  inherit- 
ance; or,  it  may  be,  he  has  been  vilified,  slandered,  hbeled,  and 
he  seeks  satisfaction  through  the  law.  Sometimes  there  is  just 
sufl&cient  basis  in  fact  to  give  coloring  to  the  patient's  conten- 
tion; i.  e.,  an  estate  has  actually  been  divided,  certain  business 
transactions  have  really  taken  place,  the  patient  did  live  in  a 
certain  neighborhood,  perhaps  did  not  have  friendly  relations 
with  those  about  him,  the  members  of  his  family  or  his  business 
associates;  but  that  he  has  suffered  wrong,  as  he  believes,  does 
not  of  course  follow.  However,  the  patient  frequently  is  so 
lucid,  and  the  presentation  of  his  case  so  plausible,  that  he  may 
have  little  difficulty  in  securing  the  services  of  an  attorney. 
Usually  the  facts  developed  subsequently  reveal  that  the  pa- 
tient has  no  case.  He  may  then  take  the  matter  to  another 
attorney;  perhaps  the  case  eventually  reaches  trial.  In- 
evitably the  absurdity  of  the  situation,  the  untenable  character 
of  the  claim,  the  hopelessly  illogic  contentions  of  the  patient, 
become  apparent,  but  he  fails  utterly  to  comprehend  that  he 
has  been  in  the  wrong,  mistaken,  or  even  that  he  has  used  bad 
judgment.  On  the  contrary,  he  now  weaves  the  lawyers,  the 
witnesses,  the  jury,  the  judges  into  a  systematized  delusion 
of  conspiracy.  His  counsel  has  played  him  false,  this  or  that 
witness  has  betrayed  him,  the  jury  has  purposely  made  common 
cause  against  him,  and  even  the  judge  has  been  in  collusion 
with  his  enemies.  One  of  these  patients  brought  action  against 
her  relatives  because  of  fraud  in  the  division  of  an  estate;  it 
was  quickly  proved  that  she  had  not  only  been  paid  her  full 
share,  but,  because  of  her  improvidence,  had  subsequently 
been  a  charge  upon  the  other  members  of  her  family.     To  show 


170  MENTAL    DISEASES 

how  inimical  her  relatives  were  to  her,  she — unexpectedly  to 
her  counsel — produced  a  bottle  containing  some  decomposed 
cherries  with  which  she  declared  they  had  attempted  to  poison 
her.  It  was  also  shown  that  she  believed  that  her  relatives 
had  wared  her  house,  and  she  had  actually,  with  a  hatchet, 
chopped  off  a  large  part  of  the  plaster  in  her  parlor  in  a  search 
for  the  wires.  Her  case  was  of  course  easy  of  solution.  Unfor- 
tunately the  situation  is  not  always  cleared  up  so  readily. 
Sometimes  the  facts  are  quite  involved  and  complicated.  Not 
infrequently,  before  the  insanity  of  the  plaintiff  is  finally  clearly 
established,  lawyer  after  lawyer  is  consulted  and  suit  after 
suit  instituted.  Often  much  suffering  and  unhappiness  result. 
Frequently,  too,  the  patient  impresses  his  delusive  ideas  on 
others,  who  become  his  partisans  and  champions.  In  the  case 
just  mentioned,  the  woman  had  impressed  one  of  her  friends, 
a  minister,  with  the  justice  of  her  claim,  and  he  had  actually 
gone  so  far  as  to  join  her  in  the  plaster-chopping  search  for 
the  wires  in  the  parlor;  the  offending  relatives  lived  next  door. 
An  interesting  and  often  troublesome  form  of  paranoia  is 
that  every  now  and  then  exhibited  by  persons  who  conceive 
it  to  be  their  mission  to  accomplish  the  social  or  poUtical  regen- 
eration of  the  world,  to  make  humanity  good  and  happy.  As 
a  rule,  they  advocate  some  utterly  impracticable  panacea  for 
the  ills  from  which  the  world  suffers;  they  aim  to  reform  the 
world  at  a  single  blow;  there  shall  be  no  more  poverty,  no  more 
injustice,  no  more  suffering;  everybody  shall  have  his  share, 
everybody  shall  be  happy;  there  shall  be  the  advent  of  the 
millenium.  These  persons  do  not,  as  a  rule,  suffer  from  hallu- 
cinations, nor  are  they  the  victims  of  mystic  ideas,  as  in  re- 
ligious paranoia;  however,  they  also  are  "called,"  have  a 
"mission"  to  perform.  As  a  rule,  hereditary  factors  are  very 
pronounced;    the  period  of  depression  is  sometimes  difficult 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  171 

to  trace,  though  not  mfrequently  there  is  an  antecedent  history 
of  a  long-continued  period  of  general  ill-health.  The  expansion 
of  the  patient  is  obvious.  He  has  an  overwhelming  confidence 
in  himself,  is  assertive  and  aggressive  to  a  degree.  He  speaks 
in  terms  of  exaggeration  alike  of  the  difficulties  with  which  he 
contends  and  of  the  great  things  he  is  going  to  accomplish. 
Quite  frequently  he  speaks,  lectures,  writes;  sees  evil  where 
others  fail  to  see  it.  As  a  rule,  the  mental  state  of  such  a 
person  becomes  evident  after  a  while  even  to  the  laity.  He 
may,  however,  for  a  long  time  obtain  a  deluded  following.  At 
times  his  ideas  are  frankly  out  of  all  keeping  with  his  sur- 
roundings, he  believes  himself  to  be  royalty  or  destined  to 
become  king  or  emperor;  sometimes  the  degeneration  progresses 
and  he  believes  himself  to  be  the  Deity.  Hallucinations  of 
hearing  are  met  with  in  a  small  number  of  cases. 

Occasionally  the  expansion  expends  itself  in  the  direction  of 
literature,  art,  or  invention.  The  individual  writes  literary 
or  scientific  articles  and  books,  undertakes  some  great  work  of 
art  upon  which  his  fame  is  to  endure  for  all  time;  or  he  devotes 
himself  to  some  invention,  quite  frequently  something  chimer- 
ical and  impossible  of  achievement,  such  as  perpetual  motion. 
As  in  the  other  ambitious  forms  of  paranoia,  the  depressive 
period  is  usually  not  marked;  at  times,  however,  we  find  traces 
of  it  in  the  long  periods  of  trial  and  discouragement  before  the 
patient  believes  that  he  has  really  attained  his  object.  Not 
infrequently  he  wastes  his  substance  in  the  attempt  to  further 
his  projects.  Throughout  he  reveals  a  personality  expanded 
beyond  all  bounds,  a  self-confidence  so  extreme  that  he  does 
not  hesitate  to  jeopardize  the  means  and  savings  of  relatives, 
friends,  and  others.  Weakness  and  absurdity,  the  gross  char- 
acters of  the  delusive  beliefs  sooner  or  later  lead  to  the  recog- 
nition of  the  truth,  happily  at  times  very  early.  (See  also 
Part  II,  Chap.  III.) 


172  MENTAL    DISEASES 

Prognosis  of  Paranoia;  General  Considerations  and  Con- 
clusions.— That  paranoia  presents  itself  under  exceedingly 
varied  forms  the  above  descriptions  clearly  show.  The  picture 
presented  by  delusional  lunacy  ranges  from  the  paranoid  de- 
mentia of  dementia  prsecox  (i.  e.,  the  paranoia  acuta  of  the 
Germans,  the  delires  systematises  aigus  of  the  French)  to  the 
lucid  states  met  with  in  the  non-hallucinatory  forms  of  para- 
noia. The  relation  between  paranoid  dementia  and  paranoia 
hallucinatoria  is,  as  has  already  been  shown,  by  the  existence 
of  transitional  forms,  one  of  degree;  cases  beginning  as  acute 
paranoia  may,  though  rarely,  pass  into  the  chronic  form,  or 
cases  eventuating  in  chronicity  may  begin  with  rather  an  active 
onset  of  symptoms.  We  have  seen  that  in  paranoia  acuta 
while,  on  the  whole,  the  outcome  is  unfavorable,  an  individual 
attack,  especially  a  first  attack,  may  terminate  in  recovery; 
and  that  years  afterward  such  an  attack  may  be  followed  by  a 
second  or  even  a  third,  mental  deterioration  becoming  finally 
more  and  more  pronounced.  These  facts  in  a  measure  fore- 
shadow what  we  are  to  expect  in  the  chronic  form.  In  para- 
noia hallucinatoria,  to  begin  with,  the  average  course  consists 
in  the  passage  of  the  patient  through  the  period  of  persecu- 
tion, the  transformation  of  the  personality,  and  the  expansive 
state,  to  a  final  period  of  deterioration  or  dementia.  The  whole 
process  extends  over  many  years— ten,  fifteen,  twenty-five — 
indeed,  it  is  practically  a  life-long  disease.  However,  we  note 
now  and  then  in  paranoia  hallucinatoria  a  distinct  abatement 
of  sj'mptoms,  and  even  at  times,  though  rarely,  a  clearly  marked 
remission.  This  is  more  apt  to  be  the  case  when  the  symptoms 
are  relatively  rapid  in  onset  and  course;  that  is,  when  they 
approximate  the  acute  form  of  dementia  paranoides.  Again, 
every  alienist  will  recall  cases  in  which  the  patient,  though 
greatly  disturbed  upon  admission  to  the  asylum,  has,  under 
the  quiet  and  simple  regime  of  the  institution,  rapidly  and 


GROUP    III — THE    HEBOID-PARANOID    AFFECTIONS  173 

greatly  improved;  sometimes  so  much  so  that  well-meaning, 
though  mistaken,  friends  or  relatives  have  insisted  upon  the 
patient's  discharge.  Such  improvement  is,  of  course,  tem- 
porary only;  the  patient's  mental  state  sooner  or  later  reasserts 
itself.  On  the  whole,  it  may  be  said  that  the  progress  of  a 
hallucinatory  paranoia  is  not  subject  to  marked  interruptions; 
such  variations  as  are  noted  are  rather  in  the  nature  of  accen- 
tuation of  symptoms  than  in  their  abatement  or  remission. 

Again,  as  a  rule,  the  progress  of  paranoia  is  steadily  toward 
mental  deterioration;  the  degree  of  change  and  the  rate  at 
which  it  is  established  vary  greatly  in  different  cases.  As  a  rule, 
in  ordinary  hallucinatory  paranoia  the  deterioration  becomes 
more  and  more  evident  as  the  years  pass  by,  until  finally  a 
stage  of  terminal  dementia  is  reached.  Relative  lucidity  may, 
however,  be  preserved  a  long  time;  especially  is  this  the  case 
in  the  mystic  form.  In  non-hallucinatory  paranoia  the  change, 
as  we  have  seen,  is  exceedingly  slow,  and  a  marked  terminal 
dementia  may  never  be  reached;  at  least  not  as  long  as  the 
patient  is   under  observation. 

Finally,  it  remains  to  emphasize  the  fixation  of  the  delusions. 
Once  they  have  become  established  and  systematized  they 
remain  unchanged,  and,  save  for  some  elaboration,  unalterable. 
In  the  hallucinatory  form,  during  the  early  period,  the  delusions, 
though  preserving  their  general  character,  may  vary  somewhat, 
but  not  after  the  affection  has  reached  its  full  evolution.  It 
is  especially  in  the  non-hallucinatory  form  that  fixation  and 
elaboration  find  their  fullest  expression.  As  has  been  pointed 
out,  the  difference  between  ordinary  hallucinatory  paranoia 
and  the  non-hallucinatory  form  is  not  as  great  as  would  at  first 
sight  seem.  Thus,  the  paranoia  which  assumes  the  artistic, 
the  literary  form,  and  more  especially  the  paranoia  which  as- 
sumes the  form  of  social,  political  regeneration,  bears  close 
resemblances  to  mystic  paranoia,  itself  a  hallucinatory  form. 


174  MENTAL    DISEASES 

This  is  also  true,  though  less  markedly,  of  the  paranoia  of  in- 
vention and  discovery. 

Paranoia  is  a  remarkable  affection,  because,  on  the  one  hand, 
it  presents  itself  with  features  so  striking  and  unmistakable 
that  even  lay  persons  recognize  the  patient  at  once  as  insane; 
while,  on  the  other,  it  may  present  itself  with  such  a  high  degree 
of  lucidity,  with  arguments  so  plausible  and  specious,  as  in  the 
paranoia  of  the  reformer,  the  agitator,  the  writer,  the  inventor, 
that  not  only  may  lay  persons  fail  to  recognize  the  insanity, 
but  may  even  adopt  the  delusive  ideas  of  the  patient,  as  in 
mystic  paranoia.  Many  of  the  non-hallucinatory  paranoiacs 
are  dangerous,  though,  on  the  whole,  they  are  less  so  as  regards 
assaults  upon  the  person  and  attempts  to  kill  than  are  ordinary 
paranoiacs.  Many  of  them  are  harmful  in  the  way  of  dissemi- 
nating dangerous  theories,  evil  cults,  and  pernicious  doctrines. 
Others  again  are  quite  harmless;  especially  is  this  the  case  with 
those  whose  delusions  are  concerned  with  literary,  scientific,  and 
artistic  projects  or  with  inventions.  Many  of  these  are  among 
the  harmless  lunatics  found  in  every  community;  some  are  so 
lucid,  and  their  views  so  plausible,  that  they  are  often  merely 
regarded  as  "cranks,"  sometimes  annoying,  sometimes  amusing, 
but  really  quite  without  danger.  Concerning  some  of  them 
even  the  opinion  of  physicians  may  differ  as  to  the  fact  of  a  real 
delusional  lunacy.  Comparatively  few  of  the  non-hallucinatory 
paranoiacs  are,  as  already  stated,  found  in  the  asylums.  They 
are  often  committed  with  considerable  risk  to  the  examining 
physicians,  and,  because  of  the  high  degree  of  their  lucidity, 
are  often  retained  in  the  asylums  with  difficulty.  Indeed,  the 
asylum  authorities  are  often  anxious  to  get  rid  of  them  because 
of  the  very  troublesome  litigation  sooner  or  later  instituted  by 
the  patient  or  misguided  friends.  As  already  pointed  out, 
the  patient  still  further  increases  the  difficulty  by  suppressing 
his  delusions. 


CHAPTER  VI 

GROUP  IV— THE  NEURASTHENIC-NEUROPATHIC 
DISORDERS    (PSYCHASTHENIA) 

The  group  of  affections  which  forms  the  subject  of  the  pres- 
ent chapter  is  one  concerning  which  much  has  been  written, 
and  concerning  which  there  has  been  much  difference  of  opinion. 
The  close  relation  which  some  of  these  affections,  more  espe- 
cially the  phobias,  bear  to  neurasthenia  was  early  recognized  by 
Beard  and  subsequently  confirmed  by  others.  In  keeping 
wdth  this  fact,  the  French  writers  applied  the  term  ''neuras- 
thenic insanities"  to  this  group.  That,  however,  some  factor 
other  than  simple  nervous  exhaustion  plays  here  a  role,  a  brief 
consideration  will,  I  beUeve,  convince  us. 

In  the  demands  that  modern  civilization  makes  upon  the 
individual,  undue  expenditure  of  energy,  an  expenditure  that 
results  in  over-fatigue,  is  of  frequent  occurrence.  More 
especially  is  this  true  if  the  individual  has  inherited  a  tendency 
to  nervous  exhaustion;  i.  e.,  a  feeble  resistance  to  fatigue. 
Under  such  circumstances  a  condition  is  estabhshed  in  which 
neither  the  normal  amount  of  rest  nor  food  suffice  any  longer  to 
restore  the  organism  to  the  equilibrium  observed  in  health. 
Gradually  a  well-defined  neurosis,  with  a  definite  symptoma- 
tology, becomes  established,  and  this  is  widely  known  among 
the  laity  as  nervous  prostration  and  among  physicians  as  neu- 
rasthenia. Its  symptomatology  is  essentially  the  symptoma- 
tology of  chronic  fatigue,  and  for  this  reason  it  well  merits  the 
term,  the  ''fatigue  neurosis,"  which  the  wTiter  has  on  various 
occasions  applied  to  it.     It  is  the  symptoms  of  this  fatigue 

175 


176  MENTAL    DISEASES 

neurosis  and  the  bearing  these  sjmaptoms  have  on  the  mental 
affections  under  consideration  which  particuhirly  concern  us. 

The  first  fact  that  impresses  us  in  neurasthenia  is  that  the 
patient  becomes  readily  exhausted.  He  is  incapable  of  the 
sustained  expenditure  of  energy.  This  is  true  whether  the 
expenditure  is  physical  or  mental.  In  keeping  with  this  fact 
is  also  that  of  irritability,  of  exaggerated  response  to  stimuli 
from  without;  that  is,  along  with  the  lessened  power  of  sus- 
tained expenditure  of  energy,  there  is  also  a  lessened  inhibition. 
There  are  present,  in  addition,  the  symptoms  of  deficient  inner- 
vation of  the  digestive  tract,  of  the  circulatory  apparatus,  and 
of  other  structures  such  as  the  sexual  organs. 

The  phenomena  presented  by  neurasthenia  naturally  resolve 
themselves  into  motor,  sensory,  general  somatic,  and  psychic 
symptoms,  and,  while  it  is  the  psychic  phenomena  which 
chiefly  concern  us,  a  brief  consideration  of  the  others  serves 
to  complete  the  picture;  besides  they  are  not  infrequently  pres- 
sent  in  a  degree  in  the  mental  affections  we  are  about  to  study. 

When  we  turn  our  attention  to  the  motor  symptoms,  we  find 
that  the  muscles  rapidly  reveal  the  signs  of  fatigue.  Thus  the 
grip  of  the  patient  is  found  to  be  weak;  occasionally,  however, 
it  seems  to  be  normal,  but,  if  it  be  tested  by  the  dynamometer 
a  munber  of  times  in  succession,  we  find  that  it  rapidly  grows 
weaker.  The  various  statements  which  the  patient  makes 
are  in  keeping  with  this  finding.  He  will  state,  for  instance, 
that  he  cannot  walk  even  for  short  distances  without  inducing 
fatigue,  and,  indeed,  that  slight  muscular  exertion  of  any  kind 
rapidly  exhausts  him.  In  keeping  ^^^th  this  ready  muscular 
exhaustion,  we  find  a  diminished  inhibition  of  the  tendon  re- 
flexes; quite  commonly  the  knee-jerks  are  exaggerated.  Some- 
times also  tremor,  irregularly  recurring  contractions  of  small 
bundles  of  muscle  fibers,  more  especially  in  the  face  and  ex- 


GROUP   IV — THE    NEURASTHENIC-NEUROPATHIC   DISORDERS       177 

tremities  (myokymia),  and  even  occasional  cramps  or  spasms 
of  muscles — e.  g.,  in  the  calves — may  be  present.  These  symp- 
toms may  be  regarded  as  adventitious,  but  are  doubtless  to 
be  interpreted  as  due  to  defective  and  irregular  innervation. 

The  sensory  phenomena  of  neurasthenia  are  altogether  sub- 
jective. The  patient  complains  of  various  fatigue  sensations, 
aches,  and  pains,  which  he  refers  to  the  trunk,  the  limbs,  the 
head.  These  sensations  are  always  brought  on  or  made  worse 
by  exertion  and  disappear  or  grow  less  upon  rest.  Quite  fre- 
quently the  patient  complains  merely  of  a  general  feeling  of 
fatigue  or  exhaustion;  at  other  times  of  lightness,  constriction, 
or  pressure  about  the  head,  or  it  may  be  of  uncertainty  and 
dizziness.  Insomnia  is  very  frequent.  It  should  be  emphasized 
that  objective  sensory  disturbances,  such  as  anesthesia  or 
hypesthesia,  are  never  present. 

The  somatic  disturbances  are,  as  already  indicated,  depend- 
ent upon  a  deficient  innervation.  Thus  the  digestive  disturb- 
ances are  primarily  those  of  weakness.  The  patient  having 
taken  food  may  feel  at  first  no  distress,  but,  after  the  lapse  of  a 
longer  or  shorter  interval,  sensations  of  weight,  oppression,  and 
of  general  discomfort  in  the  epigastrium  make  their  appearance; 
perhaps  there  are  eructations.  The  patient,  we  learn,  is  also 
constipated.  In  other  words,  the  symptoms  are  those  of  an 
atonic  indigestion.  There  is  not  a  sufficient  flow  of  nervous 
energy  to  the  glands  and  muscular  coats  of  the  stomach  and 
intestines  to  allow  either  a  sufficient  secretion  of  gastric  or  in- 
testinal juice,  or  a  sufficient  movement  in  the  walls  of  the  stom- 
ach and  intestines. 

When  we  turn  our  attention  to  the  circulatory  apparatus, 
the  same  fact  of  deficient  innervation  becomes  evident.  We 
note  coldness,  and,  in  marked  cases,  lividity  of  the  extremities. 
At  the  same  time,  we  find  modifications  in  the  force  and  rhythm 

12 


178  MENTAL    DISEASES 

of  the  heart's  action,  in  the  character  and  frequency  of  the  pulse, 
and  more  or  less  marked  alterations  in  the  vaso-motor  tonus. 
However,  the  most  striking  circulatory  disturbance  in  neuras- 
thenia is  palpitation  of  the  heart;  at  times  there  is  present  a 
more  or  less  persistent  tachycardia.  Everywhere  we  note  the 
fact  of  deficient  innervation  and  deficient  inhibition;  for  in- 
stance, the  presence  of  pulsation  of  the  aorta  or  great  vessels 
generally  or  of  local  pallor  or  flushing  of  various  portions  of  the 
surface  or  extremities. 

The  circulatory  phenomena  of  neurasthenia  are  of  great 
importance  in  relation  to  the  mental  affections  of  the  present 
group.  Thus,  fear  is  normally  and  intimately  associated  with 
quickening  of  the  pulse-rate,  often  with  a  frank  and  outspoken 
palpitation  of  the  heart,  sudden  pallor,  and  other  vascular 
phenomena.  That  these  stand  in  a  causal  relation,  or  at  least 
in  so  close  a  relation  to  spontaneous  attacks  of  fear  in  neuras- 
thenia that  they  cannot  be  dissociated  is  exceedingly  probable. 
In  other  words,  just  as  an  attack  of  fear,  brought  on  in  a  normal 
individual  by  a  sudden  physical  danger,  is  attended  by  palpi- 
tation and  other  vascular  disturbances,  so  may  this  very  pal- 
pitation of  the  heart,  coming  on  suddenly  and  spontaneously, 
in  its  turn  evoke  the  associated  emotion  of  fear.  That  this 
actually  occurs  in  neurasthenic  patients  is  a  clinical  fact. 

Among  the  more  important  somatic  phenomena  are  to  be 
included  the  sexual  disturbances.  These  are  in  the  main  those 
of  irritable  weakness.  Occasionally  they  are  so  marked  as  to 
form  a  prominent  part  of  the  clinical  picture.  Although  the 
objects  of  the  present  chapter  forbid  an  extended  considera- 
tion, a  brief  smnmary  of  the  symptoms  is  necessary  in  order 
that  the  importance  and  even  magnitude  of  the  role  which 
they  sometimes  play  may  be  understood.  Not  rarely  the 
patient,  if  a  man  and  unmarried,  presents  the  symptom  of 


GROUP   IV — THE   NEURASTHENIC-NEUROPATHIC   DISORDERS       179 

unusual  frequency  of  seminal  emissions,  or,  if  married,  may 
present  the  symptom  of  premature  ejaculation  or  of  the  sexual 
act  being  incomplete  and  unsatisfactory  in  other  ways.  In 
women  symptoms  corresponding  to  those  in  the  male  may 
occur.  Not  infrequently,  a  patient  complains  of  orgasms  oc- 
curring during  sleep,  and  may  state  that  these  are  accompanied 
by  oppressive  and  voluptuous  dreams.  If  married,  such  SJ^np- 
toms  are  less  likely  to  be  present,  but  the  patient  may  complain 
of  some  abnormality  of  the  sexual  act.  There  may  be  failure  of 
proper  response,  frigidity,  delay,  or,  as  in  the  male,  the  act 
may  be  incomplete  and  unsatisfactory.  These  symptoms, 
whether  occurring  in  men  or  women,  are  usually  but  a  part 
and  parcel  of  the  symptom  group  of  the  general  neurasthenia 
and  are  directly  dependent  upon  it.  They  are  due  to  the  ex- 
haustion, just  as  much  as  are  the  digestive  or  the  circulatory 
phenomena,  but,  because  they  are  sexual,  their  importance 
becomes  exaggerated  in  the  patient's  mind  and  their  signifi- 
cance misinterpreted.     To  this  subject  we  "wall  return  later. 

Without  pausing  to  consider  other  somatic  phenomena  of 
neurasthenia,  let  us  turn  our  attention  to  the  psychic  symp- 
toms, which  are,  after  all,  the  most  important. 

The  psychic  disturbances  present,  as  already  indicated,  first, 
ready  mental  exhaustion.  There  is  marked  diminution  in  the 
capacity  for  sustained  mental  effort.  There  is  difficulty  in 
sustaining  and  concentrating  the  attention  and  there  is  also  a 
marked  diminution  in  the  spontaneity  of  thought.  At  the  same 
time,  the  patient,  who  is  chronically  tired,  loses  some  of  his 
personal  force,  aggressiveness,  and  will-power.  He  becomes 
unable  to  decide,  "wdth  his  usual  readiness,  matters  of  business, 
even  ordinary  or  trivial  matters.  Unpleasant  and  pleasant 
matters  ahke  are  deferred;  everything  that  requires  any  effort 
remains  undecided.     Finally,  lack  of  spontaneity  and  lack  of 


180  MENTAL    DISEASES 

will-power  may  be  frankly  accompanied  by  uncertainty,  hesita- 
tion, and  habitual  indecision. 

Again,  there  is  a  markedly  increased  irritability;  i.  e.,  a 
dmiinution  of  inhibition.  That  the  tired  man  is  cross  is  as 
well  known  to  the  laity  as  to  ourselves;  his  irritability  is  only 
a  more  or  less  marked  loss  of  self-control,  i.  e.,  of  inhibition.  He 
becomes  excited  more  readily,  uses  expletives  and  expressions, 
says  things  to  which,  when  not  tired,  he  would  not  give  vent. 
His  emotions  generally  are  aroused  more  easily  than  normally. 
He  not  only  becomes  angry  more  easily,  but,  on  the  other  hand, 
a  play  at  the  theater  or  a  newspaper  account  of  a  tragedy  may 
move  him  to  tears. 

In  addition,  the  patient  frequently  presents  the  symptoms 
of  fear.  That  a  person  whose  nervous  system  is  exhausted 
should  also  be  morbidly  afraid  is  perhaps  not  surprising,  for 
weakness  and  fear  seem  naturally  to  be  associated.  The  degree 
of  the  emotion  varies  greatly  in  different  patients.  It  may  be 
vague,  subconscious,  ill-defined,  and  may  be  looked  upon  as 
the  natural  concomitant  of  the  other  mental  symptoms; 
namely,  the  lack  of  ^^ill-power,  the  uncertainty,  the  indecision. 
At  times  the  fear  amounts  to  a  general  feeling  of  anxiety.  At 
other  times  it  comes  on  in  sudden  attacks,  attacks  which  are 
generalized  in  character,  and  which  may  be  properly  spoken 
of  as  attacks  of  spontaneous  generalized  fear.  Typical  of  such 
attacks  are  those  which  in  some  neurasthenics  accompany 
attacks  of  palpitation  of  the  heart.  Under  these  circmnstances 
the  patient  becomes  anxious  and  distressed,  and  at  times  very 
much  frightened.  There  is  a  sense  of  distress  in  the  precordia — 
a  "pain  about  the  heart" — and  the  patient  may  feel  as  though 
something  terrible  were  about  to  happen,  as  though  death 
itself  were  impending.  There  is  a  sudden  onset  of  tachy- 
cardia, the  pulse  becomes  small  and  rapid,  the  face  pale,  the 


GROUP   IV — THE   NEURASTHENIC-NEUROPATHIC    DISORDERS       181 

expression  anxious,  the  respiration  hurried  and  irregular.  If 
the  attack  be  severe  the  symptoms  may  not  stop  here,  but  the 
patient  may  break  out  into  a  cold  sweat,  he  may  become  faint, 
the  limbs  may  become  relaxed,  he  may  sink  into  a  chair  or 
even  to  the  ground.  As  in  intense  fright  from  other  causes, 
the  sphincters  may  become  relaxed.  The  bowels  or  the  bladder 
may  be  suddenly  evacuated.  Severe  attacks  occur,  especially 
in  women,  and  they  vary  of  course  greatly  in  degree;  from  a 
mere  "fluttering"  of  the  heart  to  a  very  grave  seizure. 

There  are  few  neurasthenics  who  are  altogether  free  from 
fear;  there  are  at  least  anxious  feelings  which  come  on  or  are 
more  pronounced  at  times,  and  it  is  a  common  experience  for 
these  feelings  to  be  accompanied  by  distress  in  the  region  of 
the  heart,  perhaps  in  the  abdomen,  or  less  frequently  in  other 
portions  of  the  body.  Sometimes  the  fear  comes  on  without 
special  visceral  symptoms,  the  patient  simply  becoming  in- 
tensely nervous,  restless,  anxious,  and  afraid.  Such  states  are 
quite  frequently  misunderstood  by  the  practitioner  and  in- 
correctly characterized  as  hysterical.  Finally,  sometimes  the 
purely  nervous  phenomena  precede,  sometimes  follow  the 
visceral  phenomena;  sometimes,  and  indeed  commonly,  both 
groups  of  symptoms  seem  to  come  on  simultaneously. 

Neurasthenia  may  present  itself,  as  above  outlined,  as  a  sim- 
ple fatigue  neurosis.  Such  a  neurosis  does  not  of  itself  lead  to 
changes  in  the  quality  of  mind,  that  is,  to  such  changes  in  the 
"manner  of  acting,  thinking,  and  feeling"  as  to  constitute 
insanity.  In  order  that  this  should  result  another  factor  must 
be  introduced,  namely,  a  more  or  less  marked  degree  of  neu- 
ropathy. A  non-neuropathic  individual  may  from  overwork 
or  other  nervous  over-strain  develop  nervous  exhaustion,  but, 
in  order  that  he  should  develop  a  psychosis,  he  must  previously 
have  been  neuropathic.     Usually  evidences  of  such  a  neurop- 


182  MENTAL    DISEASES 

athy  are  revealed  both  in  the  make-up  and  in  the  heredity  of 
the  individual.  It  is  only  when  fatigue  symptoms  appear  in 
such  a  subject  that  mental  disease  results.  This  truth  will 
become  more  evident  as  we  proceed. 

In  order  that  we  should  have  adequate  conceptions  of  this 
underlying  neuropathy,  it  is  necessary  to  learn  in  what  manner 
of  person  these  affections  make  their  appearance.  We  soon 
learn  that  they  come  on  in  individuals  who  for  a  long  time 
previous  to  the  establishment  of  the  symptoms  have  not  been 
normal.  Often  we  receive  a  history  that  in  childhood  the 
patient  was  unduly  impressionable,  timid,  shy,  undecided,  and 
lacking  in  initiative.  Quite  commonly,  it  is  the  history  of  a 
child  easily  dominated  by  its  fellows,  not  joining  the  latter  in 
their  play,  awkward  and  even  clumsy  in  physical  exercise,  and 
often  betraying  peculiarities  of  gesture,  little  tricks  of  move- 
ment, twitchings  of  the  facial  muscles,  head,  or  limbs;  often, 
too,  it  is  the  history  of  a  child  fussy  or  fastidious  in  the  extreme 
about  its  clothing  or  belongings,  or,  on  the  other  hand,  excess- 
ively conscientious,  exaggerating  the  importance  and  gravity 
of  its  little  misdemeanors,  faults,  or  peccadillos;  sometimes  it 
is  the  history  of  a  child  given  unduly  to  reflection,  rumination, 
day-dreaming,  and,  at  the  same  time,  of  irritable,  unstable, 
changeable  temperament. 

About  the  time  of  puberty,  the  peculiarities  of  the  patient 
may  become  more  pronounced.  Thus,  the  morbid  conscien- 
tiousness previously  noted  becomes  accentuated  and  the  pa- 
tient may  become  scrupulous  to  a  degree.  Sometimes  this 
scrupulousness  concerns  itself  with  duties  at  school  or  other 
tasks,  sometimes  with  religious  matters.  The  other  peculiari- 
ties— the  hesitation,  the  indecision,  lack  of  action,  tricks  of 
manner — may  also  become  emphasized. 

This  is  the  fertile  soil  upon  which  the  neurasthenic-neuro- 


GROUP   IV— THE   NEURASTHENIC   NEUROPATHIC-DISORDERS       183 

pathic  mental  disorder  develops;  but,  before  taking  up  in 
detail  the  mental  sjTnptoms  of  the  latter,  let  us,  as  in  the  con- 
sideration of  neurasthenia,  first  turn  our  attention  to  the 
physical  symptoms.  In  a  general  way,  we  find  that  the  latter 
are  the  same  as  those  present  in  neurasthenia,  and  they  vary  in 
degree  from  those  of  simple  nervous  fatigue  to  those  of  pro- 
nounced nervous  exhaustion.  The  motor  phenomena  are 
evidenced  by  readiness  of  fatigue,  a  want  of  energy,  an  absence 
of  resistance  to  tire.  The  sensory  phenomena  are  revealed  by 
pains  in  the  head,  trunk,  and  extremities.  The  headaches  are 
not  infrequently  pronounced  and  tenacious  and  are  often  de- 
scribed as  neuralgias.  Sometimes,  as  does  also  the  ordinary 
neurasthenic,  the  patient  complains  of  fulness  and  tension  in 
the  head,  or  of  pressure  in  the  temples  and  back  of  the  neck. 
Now  and  then  he  describes  bizarre  sensations,  such  as  shaking 
or  creaking  in  the  head,  or  a  feehng  as  though  the  head  were 
empty  or  caving  in.  Sometimes,  too,  he  speaks  of  dizziness. 
Quite  frequently  he  complains  of  insomnia. 

DigestiA''e  disturbances,  as  in  neurasthenia,  are  constantly 
present.  As  before,  they  are  characterized  by  delayed  and 
enfeebled  digestion,  sensation  of  weight  and  fulness,  distension, 
eructations,  constipation,  offensive  breath;  in  short,  by  the 
signs  of  gastro-intestinal  atony.  As  in  neurasthenia,  also,  the 
appetite  is  weU  preserved  or  even  exaggerated;  sometimes  a 
bulimia  is  present. 

On  the  part  of  the  circulatory  apparatus  we  note  that  palpi- 
tation of  the  heart  is  very  frequent;  indeed,  that  the  cardiac 
rhythm  is  very  variable.  As  before,  there  are  also  the  general 
signs  of  loss  of  vascular  tone,  pallor,  coldness  of  extremities, 
flushes  of  the  face  or  other  portions  of  the  body.  In  other 
words,  the  circulatory  phenomena  are  identical  -v^dth  those  of 
ordinary  neurasthenia.     The  skin  is  sometimes  dry;    much 


184  MENTAL    DISEASES 

more  frequently  the  patient  perspires  very  easily;  quite  com- 
monly the  hands  are  not  only  cold  but  moist.  Sometimes  the 
patient  sweats  very  readily  about  the  head  and  neck. 

As  in  neurasthenia  proper,  the  sexual  functions  present  the 
phenomena  of  irritable  weakness ;  there  is  a  history  of  excessive 
nocturnal  emissions,  or  in  coition  the  erection  is  apt  to  be  in- 
complete and  the  ejaculation  premature.  Similar  conditions 
to  those  already  outlined  as  occurring  in  the  female  in  neuras- 
thenia also  obtain  here.  Indeed,  in  both  male  and  female  the 
symptoms  are  identical  with  those  already  outlined  for  neu- 
rasthenia, save  that  they  may  even  be  more  pronounced.  (See 
p.  179.) 

An  important  point  also  to  be  borne  in  mind  is  that  a  certain 
number  of  the  patients — a  small  number — present  the  signs  of 
deficient  thyroid  activity.  This  is  seen  in  some  by  an  un- 
doubted, though  perhaps  slight,  infiltration  and  dryness  of  the 
skin,  by  a  pulse  rate  which  is  rather  slow,  and  by  a  significant, 
though  not  marked,  retardation  or  slowing  in  the  mental  pro- 
cesses. There  are  not  present  the  clearly  marked  symptoms 
of  a  myxedema,  merely  the  signs  of  a  moderate  degree  of  thy- 
roid inadequacy. 

Let  us  now  turn  our  attention  to  the  psychic  symptoms  met 
with  in  neurasthenic-neuropathic  mental  disease.  These  are 
separable  into  general  and  special  symptoms.  The  first  are 
part  and  parcel  of  the  state  as  a  whole,  and  are  found  in  all 
cases;  the  second  give  to  individual  cases  their  special  clinical 
characters.  The  first  resemble  the  general  features  met  with 
in  neurasthenia.  For  instance,  the  lack  of  sustained  effort 
and  spontaneity  is  here  also  present  and  is  clearly  recognized 
by  the  patient.  The  latter  has  a  sense  of  "inadequacy," 
of  powerlessness,  of  insufficiency.  The  patient  is  hesitating, 
irresolute,  timid,  fearful.     The  feeling  of  inadequacy  reveals 


GROUP   IV — THE    NEURASTHENIC-NEUROPATHIC    DISORDERS       185 

itself  both  in  the  actions  and  in  the  mental  operations  of  the 
patient.  Merely  the  idea  of  having  something  to  accomplish 
may  frighten  the  patient,  so  convinced  is  he  of  his  powerlessness 
to  achieve  a  result.  He  can  do  nothing  like  the  rest  of  the 
world;  sometimes  he  feels  that  he  cannot  make  a  single  gesture 
freely  and  with  ease.  This  feeling  of  inadequacy  is  usually 
exaggerated  if  the  task  or  movement  is  new  or  if  the  patient 
happens  to  be  in  the  presence  of  strangers  or  in  public.  Some- 
times the  feeling  is  so  pronounced  as  to  lead  to  discouragement 
and  hopelessness  on  the  part  of  the  patient  and  even  to  a  pro- 
found inertia.  If  the  patient  attempts  mental  work,  this  like- 
wise is  difl&cult,  impossible;  the  patient  is  incapable  of  persist- 
ence and  concentration.  This  condition  is,  of  course,  insep- 
arable from  an  impairment  of  the  will,  and  coupled  with  it  there 
is  a  feeling  of  uncertainty  and  doubt.  That  there  is  also  a 
diminished  inhibition,  that  the  patient  is  easily  upset,  excited, 
and  disturbed,  and  that  he  is  also  the  victim  of  fear,  continuous 
or  coming  on  in  attacks,  need  hardly  be  pointed  out. 

To  these  general  symptoms  there  are  added  special  symptoms 
and  thus  arise  the  various  clinical  forms.  These  have  been 
variously  grouped  by  different  writers,  but  the  following  classi- 
fication, which  I  have  employed  for  many  years,  seems  to  be 
natural  and  to  represent  the  actual  clinical  findings: 

First,  the  Insanity  of  the  Special  Fears  (the  phobias  and 
obsessions,  the  anxiety  psychoses). 

Second,  the  Insanity  of  Indecision. 

Third,  the  Insanity  of  Deficient  Inhibition. 

Fourth,  the  Insanity  of  Deficient  Will. 

It  is  at  once  seen  that  each  of  these  forms  or  symptom-groups 
has  its  prototype  in  the  psychic  phenomena  present  in  ordinary 
neurasthenia. 

The   special   fears   differ   from   the   general   fears,   in   that 


186  MENTAL    DISEASES 

they  are  related  to  special  places,  special  objects,  special 
events,  or  occurrences.  How  some  of  them  may  arise  can  be 
readily  understood.  For  instance,  a  patient  has  a  spontaneous 
attack  of  generalized  fear,  such  as  has  been  described.  If  the 
patient  be  merely  neurasthenic — that  is,  have  a  nervous  ex- 
haustion merely  expressive  of  chronic  over-fatigue  and  oc- 
curring in  an  individual  not  especially  neuropathic — the 
attack  may  pass  off  without  leaving  any  persistent  after- 
effects; but  if,  in  addition  to  being  neurasthenic  the  patient  be 
also  neuropathic — i.  e.,  if  he  have  the  psychic  and  physical 
features  already  outlined — a  pathologic  association  may  be 
formed  in  the  patient's  mind,  so  that  the  emotion  of  fear  be- 
comes linked  to  certain  relations  of  the  environment.  Thus, 
a  man  has  an  attack  of  spontaneous  generalized  fear  while 
crossing  an  open  space;  immediately  there  is  formed  in  his 
mind  an  association  between  the  attack  of  fear  and  the  open 
space,  so  that  afterward  every  attempt  to  cross  an  open  space 
brings  on  an  attack  of  fear.  The  association  between  the  open 
space  and  the  fear  is  of  course  pathologic  and  would  not  be 
formed  in  a  normal  individual.  It  is  extremely  probable  that 
a  large  number  of  the  various  special  fears  arise  in  some  such 
manner.  The  fear  of  open  spaces  is  known  technically  as 
agoraphobia.  Similarly,  the  fear  may  arise  of  being  in  a  small 
room,  a  closed  space,  a  claustrophobia.  At  another  time  it 
may  be  the  fear  of  being  in  crowds,  anthropophobia;  at  others 
still  of  being  alone,  monophobia.  The  number  of  forms  which 
the  fear  may  assume  is  of  course  very  large.  It  may,  for  in- 
stance, relate  to  special  conditions  of  the  environment;  the 
patient  may  be  morbidly  afraid  of  the  dark,  nyctophobia;  or 
contact  with  certain  substances;  e.  g.,  glass  may  give  rise  to  the 
fear,  crystallophobia.  The  tendency'  to  multiply  names  to 
characterize  these  conditions  has  happily  grown  less.    Some  of 


GROUP   IV — THE   NEURASTHENIC-NEUROPATHIC   DISORDERS       187 

them  are,  however,  worthy  of  being  retained,  as  they  serve  to 
at  once  convey  the  idea  of  the  character  of  the  symptoms 
present.  Among  them  is  the  term  mysophobia,  used  to  desig- 
nate the  fear  of  filth.  In  this  condition  the  patient  is  constantly 
washing  his  hands,  his  face,  his  head,  his  person,  in  a  vain 
endeavor  to  remove  filth  or  to  rid  himself  of  germs. 

The  phobias  and  obsessions  may  have  an  origin  in  which  the 
special  fear  is  not  based  upon  a  spontaneous  attack,  but  upon 
some  special  occurrence  or  produced  by  some  kindred  painful 
emotional  state — dread,  dislike,  disgust,  abhorrence.  A  repri- 
mand at  school  may  be  followed  by  a  phobia  with  regard  to  a 
certain  class-room,  a  certain  school  book,  a  certain  teacher. 
Unpleasant  experiences  at  home,  or,  in  older  patients,  in  busi- 
ness, may  be  followed  by  obsessions.  Sometimes  the  original 
cause  is  forgotten,  but  the  obsession,  the  phobia,  persists.  Of 
course  such  symptoms  can  arise  only  in  neuropathic  subjects, 
and  are  not  to  be  confounded  with  the  corrective  memories 
produced  in  the  child  by  punishments,  or  in  the  adult  by  the 
wholesome  and  often  trying  experiences  of  his  career. 

Among  the  causes  of  the  special  fears  are  at  times  various 
acts  of  the  patient,  breaches  of  conduct,  of  the  proprieties, 
peccadillos  of  various  kinds,  of  which  he  is  subsequently 
ashamed  and  which  he  willingly  tries  to  forget.  Among  these 
are  frequently  acts  relating  to  his  sexual  life.  It  may  happen 
that  the  patient  presents  a  history  of  masturbation,  or  perhaps 
of  repeated  prolonged  and  unsatisfied  sexual  excitement,  such  as 
may  occur  in  engaged  persons ;  or  the  patient  may  have  had  other 
sexual  experiences,  physical  or  mental,  unnecessary  to  describe 
in  detail,  and  which  are,  at  the  present  time,  embraced  by  the 
expression  "sexual  traumata,"  in  common  use  among  a  certain 
class  of  medical  writers.  Because  of  the  peculiar  relation  which 
the  sexual  functions  bear  to  the  moral  and  social  life  of  the  in- 


188  MENTAL    DISEASES 

dividual,  the  patient  is  apt  to  ascribe  his  nervous  exhaustion, 
with  its  train  of  distressing  symptoms,  to  the  masturbation, 
coitus  interruptus,  reservatus,  or  other  sexual  misconduct  that 
he  or  she  has  practised  or  permitted.  In  other  words,  the  pa- 
tient may  develop  a  nosophobia  which  centers  about  sexual 
ideas.  As  a  matter  of  fact,  the  experience  of  physicians  has 
increasingly  shown  that  the  physical  consequences  of  mastur- 
bation or  of  modifications  of  the  sexual  act — e.  g.,  the  use  of 
the  cover,  withdrawal  or  reservation  of  emission — are  not  as 
grave  or  as  baneful  as  they  are  commonly  supposed  to  be.  In 
fact,  their  evil  consequences  have  been  much  exaggerated. 
Persons  of  ordinary  healthy  make-up  often  show  surprisingly 
few  symptoms  as  a  result  both  of  unphysiologic  as  well  as  of 
excessive  sexual  living.  Two  truths  become  apparent;  first, 
the  effect  of  a  sexual  transgression  is  not  so  much  physical  as 
mental.  The  individual  usually  tries  to  forget  or  repress  the 
recollection  of  an  incident  which  is  quite  usually  followed  by  an 
unpleasant  revulsion  of  feeHng;  that  is,  after  a  "sexual  trauma," 
the  incident  is  associated  unpleasantly  in  the  patient's  mind, 
and  is,  as  far  as  possible,  excluded  from  the  field  of  conscious- 
ness. The  second  truth,  which  will  become  more  apparent  a 
little  later,  is  that  the  greater  the  tendency  to  nosophobia  and 
introspection,  the  greater  the  effect  on  the  mind  both  of  the 
sexual  symptoms  present  in  a  given  case  and  of  past  sexual 
traumata. 

Again  stress  must  be  laid  upon  the  factor  of  neuropathy.  In 
an  individual  otherwise  normal,  sexual  traumata,  so-called, 
have  but  little  effect,  but  if  he  have  the  neuropathic  make-up 
here  described,  their  influence  may  be  far-reaching  and  per- 
sistent, and  thus  may  prove  a  manifold  cause  of  fears  and  ob- 
sessions.    (See  Part  III,  Chapter  I.) 

The  insanity  of  indecision  (the  folie  du  doute,  Gruebelsucht) 


GROUP    IV ^THE    NEURASTHENIC-NEUROPATHIC    DISORDERS        189 

is  merely  an  exaggeration  of  the  mental  state  so  often  observed 
in  the  ordinary  neurasthenic,  save  that  it  now  presents  itself 
in  an  extreme  degree.  The  patient  may  betray  his  indecision 
about  the  simplest  acts,  such  as  dressing,  arranging  his  cloth- 
ing, putting  an  address  on  a  letter.  Many  minutes  and  hours 
may  thus  be  consumed.  One  of  my  patients  would  begin  to 
dress  at  about  half  past  seven  in  the  morning,  but  he  could 
rarely  get  out  of  his  room  before  twelve.  He  would  put  on  an 
article  of  clothing,  would  doubt  whether  he  had  put  it  on  right, 
would  take  it  off,  put  it  on  again,  and  repeat  this  act  inter- 
minably. Especially  was  the  difl&culty  at  its  maximum  when 
he  attempted  to  put  on  his  neck-tie;  he  could  never  get  it 
adjusted  properly.  Another  of  my  patients  could  never  enter 
a  room  without  counting  her  footsteps,  and  then  suffered  in- 
tensely because  she  was  uncertain  as  to  what  the  number  really 
was.  The  patient  is  never  quite  sure  that  that  which  he  has 
done  has  been  done  correctly.  On  going  to  bed  he  may  spend 
endless  time  in  undressing,  in  arranging  his  clothing  upon  the 
chairs  or  other  furniture,  and  may  finally  turn  out  the  gas 
and  go  to  bed.  It  is  not,  however,  to  sleep,  but  only  to  leave 
his  bed  to  see  whether  he  has  really  turned  off  the  gas;  he 
feels  the  key,  is  not  certain,  relights  the  jet,  again  turns  the 
key,  goes  to  bed,  but  only  to  rise  again  and  to  repeat  the  per- 
formance; indeed,  he  may  spend  a  large  part  of  the  night  in 
this  hopeless  effort  to  be  certain.  Similarly  he  may  spend  half 
the  night  locking  and  unlocking  doors.  Again,  a  bookkeeper 
who  had  been  very  expert  in  adding  long  columns  of  figures 
finally  broke  down,  and  began  to  be  uncertain  about  his  totals. 
He  was  compelled  to  re-add  the  same  columns  time  after  time, 
and  had  often  to  abandon  the  task  in  a  perfect  agony  of  doubt, 
utterly  exhausted. 

The  symptom  of  indecision  is,  as  we  have  seen,  already  part 


190  MENTAL    DISEASES 

and  parcel  of  the  impressionist  background  of  neuropathy  seen 
in  the  child  and  that  it  becomes  more  pronounced  as  puberty 
and  adolescence  are  reached.  Quite  commonly  the  worries  and 
doubts  of  the  child  concern  themselves  with  school  duties,  as 
we  have  already  pointed  out.  As  it  grows  older,  the  indecision, 
instead  of  expressing  itself  in  hesitation  of  action,  may  expend 
itself  upon  purely  subjective  matters.  Something  that  it  has 
read  or  heard  in  conversation  on  the  subject  of  religion  or  morals 
may  give  rise  to  endless  scruples  and  doubt  regarding  its  own 
conduct.  Sometimes  a  special  character  is  given  to  the  scruples 
by  some  other  experience,  an  emotional  shock,  such  as  the  dis- 
covery of  the  facts  of  reproduction  or  of  other  sexual  matters. 
Some  patients  spend  their  time  in  speculating  upon  or  doubting 
the  reality  of  things;  others  still  are  unhappy  because  on  enter- 
ing a  room  they  are  not  certain  of  the  number  of  chairs  it  con- 
tains, of  the  number  of  books  upon  the  table,  or  of  the  number 
of  burners  on  the  chandelier.  Consequently  they  count  and 
count  again,  and  are  never  quite  certain,  or  must  keep  on 
counting  to  reassure  themselves. 

The  symptom  group,  termed  by  the  writer  the  insanity  of 
deficient  inhibition,  is  among  the  most  interesting  that  we  have 
to  study.  It  embraces  the  great  mass  of  cases  with  "tics," 
"impulsive  movements,"  "impulsive  tendencies,"  and  "im- 
pulsions" generally.  The  English  writers  use  the  term  in- 
sanity with  irresistible  impulse,  the  French  speak  of  obsessions 
with  irresistible  tendencies,  while  the  Germans  have  largely 
employed  the  expression  "Zwangsneurose,"  compulsion  neu- 
rosis. 

The  brain,  under  normal  conditions,  is  constantly  eliminating 
impulses.  These  impulses  are  the  resultants  of  the  interaction 
of  the  mind — its  previously  acquired  memories,  associations, 
and  activities — with  the  environment.     These  impulses  are 


GROUP   IV — THE   NEURASTHENIC-NEUROPATHIC    DISORDERS       191 

normally  controlled,  restrained,  inhibited;  they  may  be  dif- 
fused or  they  may  be  directed  into  special  channels,  and  thus 
expend  themselves  in  movements  or  determinations.  These 
movements  or  determinations  are  normally  purposive  and  use- 
ful to  the  organism ;  they  may  enable  it  to  accomplish  a  definite 
object,  or  they  permit  of  the  harmless  or  pleasurable  release 
of  energy.  The  control  and  inhibition  are  alike  potent — indeed, 
are  more  forcibly  exercised — when  the  discharge  of  the  impulse 
is  attended  by  displeasure,  disgust,  or  pain. 

In  the  pathologic  state  we  are  st/udying  there  is  an  absence 
of  such  inhibition.  For  instance,  a  patient  attempts  to  carry 
on  a  conversation;  every  sentence  that  he  utters  is  interlarded 
by  a  recurring  word  or  phrase  that  has  no  relation  whatever 
to  the  content  of  the  sentence  and  is  entirely  foreign  to  any- 
thing the  patient  intends.  Quite  frequently  it  is  a  vulgar  word, 
an  oath,  an  obscene  or  profane  expression,  that  is  thus  inter- 
jected into  the  patient's  speech.  Less  frequently  it  is  a  harm- 
less phrase.  The  symptom,  which  is  known  as  coprolalia, 
occurs  in  spite  of  the  patient's  will;  he  is  anxious  to  prevent  it, 
but  is  powerless  to  do  so;  in  other  words,  there  is  a  failure  of 
inhibition.  It  is  very  apparent,  however,  that  there  is  another 
factor  to  be  considered,  and  that  is  the  origin,  the  raison  d'etre, 
of  the  word  or  phrase  which  thus  forces  itself  to  the  surface. 

We  have  earlier  pointed  out  that  in  the  underlying  neu- 
ropathy of  the  neurasthenic-neuropathic  patients  there  is  a 
group  of  general  symptoms,  and  that  each  case  is  classified  in 
accordance  with  the  predominance  of  this  or  that  special 
symptom.  It  follows,  therefore,  that  a  case  presenting  a 
phobia  also  presents  indecision,  though  less  prominently; 
similarly,  a  case  whose  principal  symptom  is  a  failure  of  inhibi- 
tion may  also  present  a  phobia  or  obsession.  It  is  such  a  phobia 
or  obsession  acquired  in  a  manner  already  indicated  which 


192  MENTAL    DISEASES 

finds  here  its  expression.  As  already  stated,  the  events  which 
give  birth  to  the  phobia  may  be  associated  unpleasantly  in  the 
patient's  mind.  There  is  an  unpleasant  feeling  which  the  patient 
tries  as  far  as  possible  to  forget;  that  is,  the  memory  of  the  origi- 
nal cause,  by  reason  of  its  unpleasant  association,  is  suppressed, 
driven  from  the  field  of  consciousness.  The  painful  feeling,  how- 
ever, persists,  and  now  forms  some  new  and  entirely  pathologic 
association  with  some  other  mental  process,  usually  an  emissive 
process.  In  keeping  with  this  is  the  fact  that  the  symptom  of 
coprolalia,  used  here  as  an  illustration,  is  quite  commonlj^  but  a 
part  of  a  larger  psychomotor  discharge;  that  is,  there  is  associ- 
ated with  the  coprolalia  a  disturbance  of  movement  known  as  a 
"tic,"  or,  when  widely  diffused  and  severe,  as  "tic  convulsif." 
These  movements  usually  have  the  appearance  of  voluntary  or 
purposive  movements,  save  that  they  occur  suddenly  and  spon- 
taneously and  usually  without  any  relation  to  the  environment. 
The  head  is  flexed  upon  the  chest  or  turned  to  one  side,  an  arm 
is  raised,  the  hand  carried  to  the  brow,  a  gesture  is  made  as 
though  the  patient  were  warding  off  something,  or  as  though 
he  were  protecting  himself  from  something  to  his  right,  to  his 
rear.  Sometimes  these  gestures  occur  in  group  movements  of 
great  violence.  Though  frequently  associated  with  coprolalia 
they  are  not  necessarily  so.  If  I  were  asked  to  name  the  one 
symptom  which  is  more  important  than  all  the  others  in  the 
neuropathy  we  are  studjang,  I  would  unhesitatingly  answer 
that  it  is  the  formation  of  abnormal,  of  pathologic,  associations. 
If  the  association  is  of  a  given  character,  an  attack  of  fear  results; 
if  of  another,  a  tic  results.  The  role  which  defective  inhibition 
plays  becomes  evident  when  we  reflect  that  the  pathologic 
associations  are  formed  in  the  same  manner  as  are  numerous 
others,  often  vulgar,  indecent,  or  profane  in  the  normal  mind, 
but  in  the  latter  such  associations  are  repressed  and  inhibited 


GROUP   IV — THE   NEURASTHENIC-NEUROPATHIC    DISORDERS        193 

successfully  and  give  no  outward  manifestation  of  their  exist- 
ence, while  in  the  neurasthenic-neuropathic  subject  they  are 
constantly  given  motor  expression.  If  in  the  neuropathic  sub- 
ject an  effort  be  made  to  suppress  them,  the  patient  suffers 
from  more  or  less  marked  distress;  this  distress,  however,  gives 
way  to  a  feeling  of  relief  the  moment  the  impulse  is  liberated. 
(See  Part  III,  Chapter  I.) 

Sometimes  the  phobia  presented  is  exceedingly  curious. 
Sometimes  the  fear  and  the  tic  are  excited  by  a  certain  number, 
such  as  13;  sometimes  by  certain  words;  sometimes  the  symp- 
tom presents  itself  in  the  form  of  kleptomania,  the  sight  of  the 
object  and  the  uninhibited  impulse  to  take  it  occurring  as  closely 
associated  phenomena.  Persons  suffering  from  this  form  of  the 
disease  will  appropriate  miscellaneous  objects  of  all  kinds, 
objects  useful  and  useless,  valuable  and  valueless.  The  thefts, 
too,  are  usually  perpetrated  in  such  a  way  as  to  lead  to  ready 
discovery;  though  the  patient,  realizing  the  possible  legal  conse- 
quences of  his  act,  not  infrequently  practices  deception  and  con- 
cealment. Pyromania  is  another  remarkable  form.  Here  the 
impulse  is  to  set  fire  to  houses,  barns  or  other  buildings.  The 
origin  of  the  impulse  is  often  difficult  of  explanation.  Curiously 
enough,  it  not  infrequently  occurs  in  connection  with  sexual 
phenomena;  for  instance,  while  puberty  is  being  established  or 
near  a  menstrual  epoch.  Possibly  at  times  suppressed  sexual 
excitement  plays  a  role.  The  impulse  occurs  at  variable  inter- 
vals and,  it  is  said,  is  preceded  by  depression,  unusual  quiet  and 
reserve.  If  the  patient  strives  to  resist  the  impulse,  more  pro- 
nounced symptoms  may  make  their  appearance.  The  patient 
may  become  nervous  and  anxious.  He  may  complain  of  head- 
ache, palpitation  of  the  heart  and  difficult  breathing.  However, 
as  soon  as  the  impulse  is  gratified,  he  experiences  a  sense  of 
satisfaction  and  relief.    The  sight  of  the  flames,  too,  is  commonly 

13 


194  MENTAL    DISEASES 

attended  by  marked  exhilaration  and  excitement,  and  not  in- 
frequently the  patient  attracts  attention  to  himself  by  his 
activity  and,  at  times,  extraordinarj^  efforts  in  helping  to  combat 
the  flames.  At  the  subsequent  investigation  he  may  appear 
as  a  witness  and  may  exhibit  marked  shrewdness  and  ability 
in  diverting  suspicion  from  himself.  If  the  truth  be  finally 
disclosed,  it  may  reveal  that  the  commission  of  the  act  was 
attended  by  much  cunning  and  premeditation.  In  the  younger 
and  more  obviously  defective  patients,  the  act  may  be  much 
more  simple  and  direct  and  be  relatively  easy  of  detection, 
and  may  find  a  ready  explanation  in  the  pleasure  which  some 
children  experience  in  playing  with  fire  and  which  others 
derive  from  the  sight  of  flames.  In  some  cases,  suggestion  and 
imitation  also  play  a  role.  Finally,  according  to  French  writers, 
pyromania  is  more  frequent  in  boys;  German  writers,  however, 
state  that  it  is  more  frequent  among  girls. 

Dipsomania  is  another  condition  commonly  grouped  with  the 
neurasthenic-neuropathic  disorders,  though  it  is  a  symptom  not 
infrequently  met  with  in  various  other  affections;  namely,  in 
manic-depressive  insanity  and  in  paresis.  Among  the  disorders 
here  considered  it  has,  however,  a  different  character.  There  is 
an  obsession,  a  phobia,  which  is  uninhibited.  Probably,  also,  we 
have  to  do  at  times  with  the  effort  to  repress  unpleasant 
memories,  and  to  which  effort  the  alcohol  is  an  undoubted 
aid.  The  diagnosis  depends,  of  course,  upon  the  history  and 
the  symptoms  presented  by  the  patient  at  a  period  when  he 
is  entirely  free  from  alcoholic  influence.  The  history  and 
symptoms,  on  the  one  hand,  of  melancholia-mania  or  of  pare- 
sis, and,  on  the  other,  of  the  characteristic  features  of  the 
neuropathy  underlying  the  special  symptoms,  would  enable 
us  to  make  a  differential  diagnosis.  Further,  in  dipsomania, 
the  drinking  is  rarely  continuous  over  a  long  period,  but  is 


GROUP   IV — THE   NEURASTHENIC-NEUROPATHIC    DISORDERS       195 

present  only  during  relatively  short  spells,  and  in  the  inter- 
vals the  patient  usually  shows  very  few  of  the  ear-marks  of 
.alcohoHsm;  sometimes  none  whatever.  During  the  attack, 
too,  it  does  not  matter  much  to  him  what  kind  of  liquor  he 
drinks.  Anything  containing  alcohol  serves  his  purpose, 
the  stronger  the  better.  If  liquors  be  not  at  hand,  alcohol 
in  any  form  is  taken,  or  it  may  be  ether,  morphia,  cocain,  or 
other  drugs. 

The  conditions  met  ^dth  in  neuropathic-neurasthenic  insanity 
are  sometimes  appealed  to  to  explain  the  impulse  to  suicide 
and  homicide.  Thus,  the  sight  of  a  weapon  may  suggest  the 
impulse  to  use  it,  either  upon  the  patient  himself  or  upon  some 
one  else.  Some  patients  when  they  handle  a  powerful  poison 
experience  an  impulse  to  swallow  it,  just  as  another  standing 
upon  a  great  height  may  experience  an  impulse  to  leap.  We 
commonly  speak  of  such  impulses  as  "irresistible,"  but  are  they 
really  irresistible?  The  patient,  it  is  true,  says  so,  asserts  it  of 
his  own  accord,  and  yet  the  facts  show  that  there  is  here  a 
great  deal  of  exaggeration.  It  has  long  been  known  that  very 
frequently,  at  least,  the  impulse  is  not  carried  out;  especially 
is  this  the  case  as  regards  suicide  and  homicide.  The  truth  is 
that  the  impulsive  tendency  is  quite  constant,  but  a  clearly 
marked,  really  irresistible  impulse  is  often  wanting.  Attempts 
at  suicide  are  very  rare,  and  really  successful  suicide  rarer  still. 
The  obsessions  are  much  less  irresistible  than  some  authors, 
following  the  assertions  of  patients,  would  lead  us  to  believe. 
Janet  has  strongly  insisted  on  this  absence  of  the  carrying  out 
of  the  impulse.  In  over  more  than  200  cases,  in  which  criminal 
impulses  were  present,  he  did  not  observe  a  single  real  occur- 
rence; he  did  not  observe  a  single  crime  committed  nor  a  single 
suicide.  The  loss  of  inhibition  is  not  as  great  as  it  seems,  and 
the  criminal  impulse  is  successfully  combated  by  the  patient. 


196  MENTAL    DISEASES 

Sometimes  the  patient  makes  use  of  means  to  prevent  the 
carrying  out  of  his  act,  which,  if  the  latter  were  really  irresist- 
ible, would  be  ridiculously  inadequate.  For  instance,  in  a 
patient  of  Marc's  it  was  sufl&cient  to  tie  the  thumbs  together 
with  a  ribbon  to  prevent  the  execution  of  the  impulse  to  homi- 
cide. That  the  statements  of  the  patient  are  commonly  quite 
exaggerated,  and  that  they  are  not  guileless,  is  quite  evident. 
Notwithstanding,  it  is  a  well-known  fact  that  suicide  among 
these  patients  does  occur.  Such  cases  have  been  observed  by 
Seglas,  Pitres  et  Regis,  and  Raymond;  the  writer  has  had  one 
such  suicide  in  his  own  experience.  The  patient  suffered 
severely  from  a  marked  tic  convulsif,  and  finally  committed 
suicide  by  drowning.  The  question  always  arises  whether  in 
such  cases  the  suicide  is  the  result  of  an  irresistible  impulse  or 
whether  it  is  the  attempt  to  put  an  end  to  the  depression  and 
despair  caused  by  an  intolerable  situation.  While  the  latter 
possibility  is  the  probable  explanation,  it  is  never  wise  to  dis- 
regard the  statement  of  the  patient  that  he  feels  that  he  must 
kill  himself. 

The  fourth  form  of  neurasthenic-neuropathic  insanity  which 
we  have  to  consider  is  the  insanity  of  deficient  will,  abulia. 
Here  the  patient  is  unable  to  carry  out  certain,  often  simple, 
acts.  As  in  stage  fright  affecting  normal  persons,  his  will 
power  fails  him.  Thus,  a  minister  is  unable  at  the  given  time 
to  ascend  his  pulpit.  He  knows  the  act  is  to  be  accompUshed, 
but  is  unable  to  force  himself  to  do  it.  The  effort,  if  persisted 
in,  is  often  accompanied  by  marked  distress,  pallor,  palpitation, 
dist\irbed  breathing.  Sometimes  the  act  which  the  patient 
fails  in  performing  is  exceedingly  simple,  such  as  rising  from  a 
chair.  Very  frequently  the  patient  can  overcome  his  inertia 
if  a  bystander  gives  a  little  support;  though  this  support  may 
be  exceedingly  slight,  it  may  serve  to  re-enforce  the  patient's 


GROUP   IV — THE    NEURASTHENIC-NEUROPATHIC    DISORDERS        197 

will-power  sufficiently  to  enable  him  to  accomplish  the  desired 
end.  That  the  abulia  is  closely  related  to  the  symptom  of 
indecision,  on  the  one  hand,  and  to  the  phobias,  on  the  other, 
is  quite  clear.  One  of  my  patients  wanted  to  go  to  a  certain 
hospital  in  the  suburbs;  considerable  time  was  lost  before  he 
finally  made  his  start.  On  arriving  within  a  few  hundred  feet 
of  the  hospital,  he  finally  became  unable  to  proceed;  he  could 
go  to  either  side,  he  could  turn  and  go  back,  but  he  could  not 
go  forward  in  the  direction  of  the  hospital.  As  he  felt  quite 
ill,  he  made  a  severe  effort  to  go,  and  actually  fell  upon  his 
hands  and  knees  and  attempted  to  crawl,  but  all  to  no  purpose. 
He  was  finally  obhged  to  turn  back,  did  so,  and  entered  a  hos- 
pital in  the  city.  Subsequently  it  was  revealed  that  a  phobia 
in  regard  to  the  suburban  hospital  had  played  a  role  equal  to 
his  abulia.  That  the  abulia  may  assume  a  great  variety  of 
forms,  such  as  an  inabihty  to  speak,  to  write,  to  pass  through 
a  certain  door,  to  perform  a  given  act,  can  well  be  imagined. 

General  Considerations,  Course,  Prognosis,  Conclusion. — 
The  various  clinical  forms  in  which  the  neurasthenic-neuro- 
pathic group  presents  itself  have  been  known  for  a  long  time. 
The  French  writers,  ever  since  the  days  of  Esquirol,  have  made 
frequent  contributions  to  the  subject;  among  the  earlier  Ger- 
man writers  it  was  more  especially  Westphal  and  Griesinger, 
and  in  our  country  it  was  Beard,  who  drew  attention  to  these 
affections.  They  were  at  first  described  as  so  many  different 
clinical  entities,  among  which  may  be  mentioned  the  various 
phobias,  obsessions,  folie  du  doute,  delire  du  toucher,  dipso- 
mania, kleptomania,  and  kindred  affections.  Attempts  were 
made  early  by  Morel,  and  later  by  Magnan,  to  reconcile  and 
reduce  to  a  general  proposition  these  apparently  dissimilar 
forms.  It  was  not,  however,  until  Raymond,  in  1892,  demon- 
strated that  folie  du  doute  and  delire  du  toucher  possessed 


198  MENTAL    DISEASES 

psychologically  identical  characters  that  a  real  advance  was 
made;  but  it  is  to  Janet  that  the  credit  is  due  of  bringing  the 
entire  group  under  one  caption,  of  embracing  all  the  apparently 
separate  forms  in  one  clinical  conception.  He  showed  that  the 
various  symptoms  which  characterize  this  or  that  form  were 
only  the  expression  of  a  deeper,  underlying  condition.  In  its 
way  Janet's  generalization  was  as  brilliant  as  that  of  Kraepelin's 
in  another  field.  Janet  gave  to  the  group,  as  a  whole,  the  name 
of  "psychasthenia,"  a  term  which  must  be  regarded  as  rather 
unfortunate;  "soul-weakness"  can  hardly  convey  a  definite 
conception,  and  if  we  render  the  term  into  "mind  or  mental 
weakness"  it  embraces  far  more  than  can  possibly  be  intended. 
I  have  for  years,  therefore,  applied  to  the  group  the  expression 
neurasthenic-neuropathic  insanity,  because,  though  long  and 
perhaps  cumbersome,  it  at  least  expresses  exactly  what  is  found, 
namely,  neuropathy  plus  nervous  exhaustion.  That  ordinary 
neurasthenia  is  closely  related  to  these  affections  has,  I  believe, 
been  abundantly  demonstrated  in  the  preceding  pages.  That 
the  underlying  neuropathy  must  also  be  accepted  as  a  clinical 
fact  goes,  I  think,  mthout  saying.  It  remains  merely  to  add 
that  in  given  cases,  though  rarely,  the  exhaustion  which  com- 
plicates the  neuropathy  may  become  so  profound  as  to  lead  to 
states  of  actual  confusion,  in  which  even  hallucinations  may 
make  their  appearance.  In  the  vast  majority  of  cases,  however, 
consciousness  is  absolutely  preserved.  Memory  is  exceedingly 
well  preserved;  sometimes  there  is  an  astonishing  minutia  of 
detail  recalled;  it  is  noticeable,  however,  that  the  memory, 
though  exceedingly  precise,  is  a  little  slow  in  its  operations. 
It  has  also  been  shown  by  Janet  and  others  that  the  reaction 
time  in  general  is  greater  than  in  normal  persons.  The  pa- 
tients are,  for  the  most  part,  intelligent;  sometimes  they  are 
endowed  with  unusual  ability,  sometimes  artistic,  sometimes 


GROUP   IV — THE   NEURASTHENIC-NEUEOPATHIC   DISORDERS       199 

literary.  The  power  of  reasoning  and  the  judgment  present 
no  noticeable  abnormality.  However,  by  reason  of  the  ex- 
haustion and  the  inherent  neuropathy — that  isj  because  of  the 
inability  to  concentrate  the  attention  and  to  keep  up  sustained 
mental  effort  for  any  length  of  time — the  ideas  lack  definiteness 
and  precision.  The  patient  tends  to  wander  from  his  subject; 
becomes  vague  and  uncertain.  This  condition  is  sometimes 
so  pronounced  that  at  certain  moments  the  patient  seems  to 
have  an  actual  suspension  of  thought,  an  "absence,"  as  it 
were.  Janet  has  given  to  this  symptom  the  name  of  "Feclipse 
mentale." 

Having  once  been  established,  the  course  of  the  affection  is 
essentially  chronic,  but  it  is  not  uniform.  There  are  times 
when  the  symptoms  are  in  abeyance  or  but  slightly  marked, 
and  there  are  times  when  the  attacks  are  pronounced  and  fre- 
quent. During  the  quiet  periods,  the  general  or  fundamental 
symptoms  of  the  affection,  already  fully  considered,  are  present, 
but  the  special  symptoms  are  lacking.  Sometimes  these  peri- 
ods of  calm  last  for  months,  sometimes  for  several  years,  and 
during  their  continuance  the  patient  may  follow — and  even 
successfully — his  avocation;  notwithstanding  there  are  moments 
when  the  quiet  is  interrupted  by  brief  and  slight  recurrences  of 
symptoms,  ominous  in  their  import.  The  active  periods  are 
characterized  by  a  return  of  the  phobia,  the  indecision,  in  fact, 
of  all  the  distressing  symptoms  in  their  full  intensity. 

Neurasthenic-neuropathic  mental  disease  persists  in  some 
cases  indefinitely;  in  a  smaller  number  it  yields  to  appropriate 
treatment,  and  in  a  still  smaller  number  ceases  spontaneously. 
In  the  most  unfavorable  cases  it  remains  stationary,  the  patient 
passing  through  a  long  series  of  periods  of  comparative  quiet 
and  comparative  disturbance.  In  the  less  unfavorable  cases, 
a  treatment  combining  both  the  principles  of  the  rest  cure  and 


200  MENTAL    DISEASES 

of  psychotherapy  may  bring  about  a  sufficient  approximation 
to  the  normal  to  permit  the  patient  to  follow  his  occupation  and 
to  meet  his  social  obhgations;  i.  e.,  it  is  possible  in  some  cases 
to  bring  about  a  practical  recovery.  In  such  recoveries,  how- 
ever, the  trained  observer  is  still  able  to  detect  the  underlying 
neuropathy.  Cases  that  cease  spontaneously  are,  as  already 
indicated,  very  infrequent;  however,  they  do  occur.  In  two 
of  my  patients,  both  of  them  typical  cases  of  agoraphobia,  the 
symptoms  disappeared  spontaneously  and  did  not,  even  after 
the  lapse  of  years,  recur. 

It  is  a  fact  worthy  of  note  that  these  patients  rarely  form 
subjects  for  asylum  commitment.  They  are  commonly  so  lucid 
and  intelligent  that  commitment  is  out  of  the  question.  It  is 
only  in  the  small  number  of  cases  in  which  the  exhaustion  be- 
comes so  grave  as  to  lead  to  mental  confusion,  a  confusion  some- 
times marked  and  accompanied  by  hallucinations,  that  such  a 
step  may  be  advisable.  There  are  cases,  too,  in  which  the  obses- 
sion becomes  so  fixed  and  dominant  as  to  rule  mercilessly  every 
waking  moment  of  the  sufferer,  or  in  which  the  symptoms  are 
of  such  a  character  as  to  make  impossible  or  impracticable  the 
continued  care  of  the  patient  in  his  own  home.  In  such  in- 
stances life  in  a  sanitorium  or  an  asylum  offers  the  only  alter- 
native. In  cases,  too,  in  which  the  impulse  leads  to  criminal  acts, 
for  instance,  in  kleptomania  and  pyromania,  the  law  may 
intervene  and  may  lead  to  trial  and  imprisonment,  or,  more 
mercifully,  to  institutional  restraint. 

In  conclusion,  in  order  that  we  may  view  the  neurasthenic- 
neuropathic  disorders,  the  psychasthenias,  in  their  proper  per- 
spective, it  is  necessary  to  call  to  mind  the  following  important 
facts.  First,  it  is  a  not  infrequent  experience  to  receive  an 
account  of  nervousness,  unusual  shyness,  diffidence  or  other 
peculiarities  in  the  ancestry;  at  times  of  symptoms  similar  to 


GROUP   IV — THE   NEURASTHENIC-NEUROPATHIC   DISORDERS       201 

those  presented  by  the  patient,  and  at  others,  especially  in  the 
graver  forms,  of  more  pronounced  nervous  disorders,  such  as 
epilepsy,  feeble-mindedness  and  alcoholism.  Secondly,  stigmata 
of  arrest  and  deviation,  though  usually  not  pronounced,  are  met 
with  in  the  patients  with  suggestive  frequency.  Finally,  it  is 
a  striking  fact,  the  significance  of  which  is  unmistakable,  that 
many  of  the  symptoms  presented  by  psychasthenics  are  also 
found  in  institutions  for  feeble-minded  children.  On  the  whole, 
the  conclusion  has  much  to  justify  it,  that  psychasthenics 
should  be  grouped  among  the  biologically  defective. 


CHAPTER  VII 

GROUP  V— THE  DEMENTIAS 

In  the  preceding  pages  we  have  considered  deUrium,  con- 
fusion and  stupor,  melanchoUa  and  mania,  the  heboid-paranoid 
group,  and  the  neurasthenic-neuropathic  insanities.  In  order 
that  our  study  of  the  fundamental  forms  shall  be  complete,  it 
remains  to  consider  dementia. 

Dementia  implies  mental  loss.  All  of  the  other  mental 
affections  thus  far  studied  present  sjonptoms  which  imply 
changes  in  the  manner  of  thinking,  acting,  and  feeling,  i.  e., 
changes  in  the  quality  of  mental  action;  in  dementia  we  deal 
with  changes  in  the  quantity  of  mind.  As  just  stated,  there  is  a 
mental  loss;  this  is  a  different  condition  from  the  deficiency  of 
mind  which  accompanies  arrested  morphologic  development, 
such  as  we  find  in  idiocy  and  imbecility.  Dementia  is  an 
acquired  mental  loss. 

Again,  dementia  is  of  two  kinds,  primary  and  secondary. 
Primary  dementia  is  a  mental  loss  that  ensues  upon  destructive 
disease  of  the  brain  tissue;  such  disease  may  be  the  outcome 
of  senile  changes,  of  disease  of  the  vessels  and  membranes,  or 
of  other  gross  lesions,  such  as  extensive  apoplexies  and  soften- 
ings, or  of  those  met  with  in  paresis.  A  secondary  dementia 
is  a  mental  loss  which  is  consequent  upon  or  tenninal  to  some 
other  mental  disease.  As  we  have  seen,  it  may  follow  one 
of  the  affections  of  the  first  group,  a  delirium,  a  confusion 
or  a  stupor,  though  this  is  infrequent.  It  may  follow  one  of 
the  manic-depressive  group,  though  this  is  rare;  we  may  recall, 
however,  that  it  is  every  now  and  then  met  ■v\ath  after  a  pro- 

202 


GROUP    V — THE    DEMENTIAS  203 

longed  melancholia  of  middle  life.  It  is  quite  common  as  the 
final  or  terminal  state  of  the  forms  of  the  heboid-paranoid 
group,  dementia  praecox  and  paranoia.  Finally,  it  is  practically- 
unknown  as  a  consequence  of  neurasthenic-neuropathic  in- 
sanity. 

Primary  dementia  is  best  illustrated  by  the  symptoms  met 
with  in  the  simple  mental  loss  that  ensues  in  some  persons  as 
they  advance  in  years,  i.  e.,  senile  dementia  of  the  simple  form. 
To  the  symptoms  of  this  simple  form  we  will  now  turn  our 
attention,  reserving  the  study  of  the  confused,  hallucinatory, 
and  paranoid  forms  for  another  chapter.  (See  Part  II,  Chap- 
ter II.)  An  adequate  conception  of  the  symptoms  of  this  simple 
mental  loss  renders  the  study  of  all  other  forms  of  dementia 
much  easier. 

Simple  senile  dementia  begins  gradually,  so  gradually  that 
those  about  the  patient  fail  to  recognize  it  until  it  is  already 
somewhat  marked.  The  mental  operations  of  the  patient 
become  slow,  and  he  has  difficulty  in  taking  in  new  ideas;  he 
becomes  unable  to  learn  new  procedures,  to  adapt  himself  to 
new  conditions.  Soon  he  is  no  longer  able  to  discharge  his 
duties,  to  do  his  work  as  well  as  formerly.  He  no  longer  uses 
his  tools  as  skilfully,  and  requires  a  much  longer  period  of  time 
in  which  to  accomplish  a  given  task.  The  latter,  when  com- 
pleted, is  not  as  good  a  piece  of  work  as  before;  indeed,  he  fre- 
quently is  compelled  to  abandon  the  task  altogether,  especially 
if  this  requires  much  accuracy  or  much  precision  of  movement. 
Likewise  his  statements  or  his  business  dealings  lack  their 
former  clearness  and  correctness.  His  judgment  also  becomes 
impaired,  and  he  begins  to  make  mistakes  in  keeping  his  ac- 
counts and  in  simple  additions.  Early  in  the  case  it  becomes 
evident  that  his  memory  is  affected.  He  becomes  forgetful, 
he  loses  and  misplaces  objects,  forgets  the  occurrences  of  the 


204  MENTAL    DISEASES 

day  and  of  the  day  before,  forgets  his  engagements.  At  first 
the  impairment  of  memory  relates  to  recent  events;  after  a 
while  it  becomes  more  general.  Sometimes  he  forgets  that  he 
has  already  attended  to  a  given  matter;  he  gives  a  clerk  the 
same  instructions  over  again;  frequently  repeats  himself,  in 
company  repeats  the  same  stories;  wanders  from  his  subject, 
forgets  the  point  of  what  he  intended  to  say;  not  infrequently 
he  becomes  garrulous.  He  loses  his  habits  of  neatness;  he 
becomes  indifferent  to  his  dress;  forgets  the  ordinary  proprie- 
ties both  of  speech  and  conduct.  Niceties  of  sentiment  and 
feeling,  the  esthetic  sense,  begin  to  disappear.  In  eating  he 
begins  to  scatter  his  food,  soil  his  clothing;  often  he  eats  in- 
differently the  food  that  happens  to  be  in  the  nearest  dish. 
He  is  not  much  concerned  with  the  events  of  his  household; 
on  the  other  hand,  he  may  be  very  cross  and  irritable. 

Soon  he  becomes  incapable  of  any  serious  or  sustained  work, 
mental  or  physical.  Little  by  Uttle  the  defects  of  memory 
grow  deeper;  not  only  recent  events,  but  those  of  the  middle 
period  of  life,  fade.  Various  forms  of  acquired  knowledge, 
foreign  languages,  attainments  of  various  kinds  are  lost.  Grad- 
ually, more  fundamental  memories  also  disappear.  The  pa- 
tient forgets  the  number  of  his  children  or  their  names,  or 
perhaps  the  fact  that  his  wife,  or  this  or  that  member  of  his 
family,  has  been  dead  many  years.  The  patient  becomes 
childish,  his  ideas  and  language  puerile.  He  is  credulous, 
with  little  Anil,  and  with  greatly  impaired  self-control.  His 
speech  becomes  incoherent,  both  from  loss  of  memory  for  words 
and  from  feebleness  of  thought. 

Things  that  he  has  been  in  the  habit  of  doing  repeatedly  for 
many  years  he  may,  notwithstanding,  continue  to  do  fairly 
well  and  for  a  long  time.  Thus,  he  may  be  able  to  endorse  a 
check  or  perhaps  sign  his  name  to  some  paper  of  which,  how- 


GROUP    V — THE    DEMENTIAS  205 

ever,  he  may  have  very  Uttle  knowledge.  A  man  in  this  con- 
dition may  also  play  a  game  which  he  has  played  a  great  deal 
during  his  life;  e.  g.,  checkers,  certain  games  of  cards.  To 
those  who  have  no  immediate  relations  or  dealings  with  the 
patient  he  may  even  present  the  appearance  of  mental  integrity. 
Indeed,  the  intellectual  void,  the  emotional  indifference,  the 
general  apathy,  often  give  the  appearance  of  calm,  of  placidity, 
serenity,  and  even  of  thoughtfulness. 

The  patient  may  eat  excessively,  and  for  a  long  time  the 
bodily  nutrition  may  be  well  preserved ;  indeed,  many  dements 
grow  fat.  After  a  while  there  is  loss  of  control  over  the  sphinc- 
ters; gradually  the  patient  begins  to  take  food  with  difficulty; 
he  loses  flesh,  becomes  bed-ridden,  and  finally  dies  of  a  bed-sore 
or  some  visceral  compHcation.  Senile  dements  sometimes  live 
a  long  time;  sometimes  for  several  years.  The  length  of  fife 
largely  depends  upon  the  personal  care  which  the  patient  re- 
ceives, and  it  is  remarkable  how  long  the  purely  organic  func- 
tions— e.  g.,  digestion  and  circulation — may  survive  the  dis- 
integration of  the  mind. 

For  an  account  of  other  forms  of  senile  dementia,  the  reader 
is  referred  to  Part  II,  Chapter  II. 


PART   II 

CHAPTER  I 

THE  CLINICAL  FORMS  OF  MENTAL  DISEASE  RELATED 
TO  THE  SOMATIC  AFFECTIONS 

In  the  preceding  pages  we  have  found  that  of  the  various 
groups  of  mental  diseases,  two — namely,  the  first,  comprising 
deUrium,  confusion,  and  stupor,  and  the  fifth,  comprising  the 
various  forms  of  dementia — are  closely  related  to  somatic 
disease;  i.  e.,  the  mental  symptoms  are  the  direct  outgrowth 
of  the  bodily  affection.  In  the  other  groups,  the  manic- 
depressive,  the  heboid-paranoid,  and  neurasthenic-neuropathic 
insanities,  the  mental  symptoms  are  clearly  the  first  in  import- 
ance, while  the  somatic  symptoms,  if  present,  are  merely  at- 
tendant phenomena.  In  the  present  chapter,  therefore,  we 
will  have  to  deal  largely  with  dehrium,  confusion,  and  stupor, 
and  to  some  extent  with  dementia.  As  these  forms  have  al- 
ready been  sufficiently  considered,  and,  in  order  to  avoid  un- 
necessary repetition,  the  characteristic  and  distinguishing 
features  only  of  the  various  special  forms  will  be  here  considered. 

The  various  somatic  affections  are  conveniently  treated 
under  the  following  heads: 

(1)  The  Infectious  Diseases. 

(2)  The  Intoxications. 

(3)  The  Disorders  of  Metabolism. 

(4)  The  Visceral  Diseases,  gross  and  malignant. 

(5)  The  Diseases  of  the  Nervous  System. 

(6)  Pregnancy,  Parturition,  the  Puerperium,  and  Lactation. 

206 


MENTAL  DISEASE  RELATED  TO  SOMATIC  AFFECTIONS  207 
1.     THE    INFECTIONS 

The  mental  diseases  which  occur  during  or  follow  the  acute 
infectious  diseases  have  already  been  considered  in  detail  in 
Part  I,  Chapter  III.  They  include  the  symptomatic  and  febrile 
deliria  met  with  in  the  period  of  invasion  and  in  the  course  of 
these  diseases,  and  also  the  delirium,  confusion  and  stupor 
met  with  during  the  period  of  convalescence  or  postfebrile 
period. ' 

The  symptom-groups  presented  differ  but  little,  whether  the 
infection  be  typhoid  fever,  pneumonia,  influenza,  erysipelas, 
septicemia,  or  the  various  exanthemata.  Certain  of  the  infec- 
tions, however,  because  of  the  peculiarities  of  the  clinical  pic- 
ture, merit  a  special,  though  brief,  description.  Among  these 
are  syphilis,  tuberculosis,  malaria,  and  pellagra. 

Syphilis. — The  mental  phenomena  of  syphilitic  infection  may 
be  divided  into  those  of  the  primary,  the  secondary,  and  the 
tertiary  stage. 

Mental  symptoms  during  the  primary  stage  are  infrequent. 
However,  we  may  meet  with  insomnia,  dizziness,  marked  as- 
thenia, depression,  hypochondriasis,  headache  and  other  pains. 
The  psychic  shock  of  the  discovery  of  having  acquired  so  terrible 
a  disease  may  also  play  a  role,  and,  in  given  cases,  hysteric 
symptoms  may  complicate  the  picture,  and  the  patient  may  give 
himself  up  to  various  nosophobic  ideas.  Sometimes  persons 
who  have  exposed  themselves  to  the  risk  of  infection,  and 
though  there  is  no  evidence  of  their  having  acquired  syphilis, 
begin  to  worry  and  may  develop  a  true  special  fear,  a  syphilo- 
phobia.  Of  course,  such  a  phobia  appears  only  in  a  predis- 
posed neuropathic  subject.  (See  p.  182.)  When  occurring  it 
is  often  intense  and  persistent.  The  patient  wanders  from 
physician  to  physician,  but  fails  to  be  reassured.  Each  time 
the  examination  results  negatively,  and  yet  soon  after  leaving 


208  MENTAL    DISEASES 

the  physician  the  torturing  doubt  returns;  the  doctor  may 
have  been  mistaken,  perhaps  he  has  syphilis  after  all,  and 
again  the  weary  pilgrimage  to  another  physician's  office  is 
undertaken.  Often  he  tries  to  get  an  appointment  with  the 
doctor  when  no  other  patients  are  waiting;  often  he  tries  to 
see  the  doctor  after  dark,  so  that  no  one  may  know  of  his  dis- 
grace. How  much  more  distressing  still  the  situation  may 
become  when  such  a  phobia  is  superimposed  upon  an  actual 
infection  may  well  be  imagined. 

Mental  symptoms  are  sometimes,  though  infrequently,  met 
with  during  the  secondary  stage.  They  are  toxic  in  their  na- 
ture. There  may  be,  in  some  cases,  toward  evening  a  little 
confusion;  at  other  times  delirium;  rarely  are  these  symptoms 
pronounced.  However,  marked  excitement,  or,  on  the  other 
hand,  heaviness  and  stupor  may  be  met  with;  sometimes  dis- 
tressing dreams  are  complained  of.  That,  in  a  neuropathic 
subject,  the  symptoms  presented  may  be  quite  severe,  need 
hardly  be  added. 

The  mental  affections  which  occur  during  the  more  advanced 
secondary  period  and  in  the  tertiary  periods  partake  more  or 
less  of  loss  of  function,  a  loss  dependent  upon  organic  changes. 
These  affections  are,  therefore,  considered  in  the  section  on 
diseases  of  the  nervous  system.  On  the  whole,  the  mental 
disorders  of  the  primary  and  early  secondary  stage  offer  a 
favorable  prognosis;  caution,  however,  should  be  exercised  in 
cases  in  which  previous  nervous  ill-health  or  a  bad  heredity 
complicates  the  picture. 

Tuberculosis. — The  recognition  by  the  patient  of  the  exist- 
ence of  tuberculosis  not  infrequently  gives  rise  to  a  marked 
depression,  hypochondriasis  and  nosophobia,  the  patient  giving 
way  to  gloomy  thoughts  and  anticipations.  At  other  times, 
more  especially  in  tuberculosis  of  the  lungs,  there  is  a  remark- 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     209 

able  and  illusory  sense  of  well-being,  a  euphoria.  The  patient 
believes  that  he  is  constantly  getting  better,  that  he  is  going  to 
get  well;  he  scouts  the  idea  of  djdng,  and  sometimes  maintains 
this  hopeful  attitude  up  to  the  ver}'  hour  of  death.  At  times 
the  euphoria  is  so  pronounced  as  to  lead  the  patient  into  what 
are  for  him  physical  excesses.  Sometimes  he  T\ill  over-exert 
himself;  at  other  times  he  will  drink  to  excess;  even  sexual 
excitation  may  be  observed. 

If  the  tuberculous  infection  be  acute  and  febrile,  as  in  miliary 
tuberculosis,  there  may  of  course  be  delirium,  or  if  in  the  course 
of  a  pulmonary  phthisis  there  be  a  febrile  rise  or  possibly  ad- 
ventitious infection  from  cavities  and  the  like,  delirium  may 
also  occur. 

Confusion  is  by  no  means  a  rare  accompaniment  of  tuber- 
culosis of  the  lungs;  sometimes  mental  symptoms  antedate  the 
frank  expression  of  lesions;  more  frequently  they  accompany 
the  appearance  of  the  physical  signs  or  follow  the  full  develop- 
ment of  the  latter.  The  confusion  is  accompanied  by  depres- 
sion, to  which  are  added  very  frequently  suspicions  and  even 
ideas  of  persecution.  It  is  not  an  uncommon  experience  for 
the  consumptive  to  beheve  that  his  food  is  being  tampered 
with,  that  something  is  being  put  into  it.  At  times  this  dis- 
trust is  so  great  that  it  leads  to  a  refusal  of  food.  That 
mental  disorders  in  tuberculosis  are  more  marked  in  predis- 
posed individuals,  in  individuals  of  a  neuropathic  make-up 
and  heredity,  need  hardly  be  emphasized.  Finally,  when  gross 
invasion  of  the  membranes  is  present,  there  are,  of  course,  the 
added  symptoms  of  tuberculous  meningitis. 

Malaria. — Malaria,  as  ordinarily  met  vnih,  is  only  infre- 
quently accompanied  by  mental  disorders.  However,  doubt- 
less owing  to  the  intensity  of  the  invasion,  to  the  neuropathy 
of  the  patient,  or  to  other  and  as  yet  unknown  adventitious 

14 


210  MENTAL    DISEASES 

factors,  delirium,  confusion,  or  stupor  may  manifest  themselves 
in  varying  degree.  Delirium  may  accompany  the  febrile 
stage;  sometimes  it  may  precede  the  latter.  Occasionally 
an  intermittent  dehrium  may  be  noted,  may  be  unaccompanied 
by  fever,  and  may  constitute  the  only  or  principal  feature; 
however,  this  is  quite  rare. 

Again,  when  the  malarial  attack  is  severe,  or  has  been  com- 
plicated by  grave  exhaustion,  confusion  may  make  its  appear- 
ance. Like  the  confusion,  the  result  of  other  infectious  pro- 
cesses, it  may  come  on  after  the  febrile  attacks  have  passed 
away  or  in  the  intervals  of  the  latter.  In  the  last  mentioned 
instances,  there  may  be  exacerbations  of  the  confusion  amount- 
ing to  dehrium  during  the  recurrences  of  temperature.  The 
confusion  is,  as  a  rule,  very  profound,  and  most  frequently 
deepens  into  stupor.  At  times  this  stupor  is  complicated  by 
convulsions,  sometimes  epileptiform,  at  other  times  tetanoid 
in  character.  The  occurrence  of  such  seizures  is  usually  indi- 
cative of  a  very  grave  degree  of  poisoning. 

In  chronic  malaria,  severe  and  persistent,  nervous  symptoms 
may  be  present,  though  they  are  not  usually  prominent.  How- 
ever, in  addition  to  marked  exhaustion  and  hebetude,  a  mild 
confusion  may  be  noted.  This  confusion  is  accompanied  by 
depression.  At  times,  also,  a  degree  of  dementia  makes  its 
appearance;  this  dementia  has,  though  improperly,  been  spoken 
of  as  malarial  paresis. 

The  prognosis  of  malarial  mental  disorders  is,  of  course, 
closely  linked  wdth  the  prognosis  of  the  malaria  itseh;  how- 
ever, they  sometimes  persist  after  the  malaria  has  been  ap- 
parently successfully  treated;  doubtless  the  exhaustion  of  the 
patient,  toxemia  and  inherent  neuropathy,  play  here  a  role. 

Pellagra. — Mental  symptoms  play  a  very  frequent  and  often 
a  very  prominent  part  in  pellagra.     This  fact  acquires  added 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     211 

importance  when  we  realize  that  the  disease  has  become  in- 
creasingly frequent  of  late  in  the  southern  and  western  parts 
of  the  United  States.  Mental  symptoms  are  the  usual  ac- 
companiments of  the  erythema,  disturbances  of  the  digestive 
tract  and  other  evidences  of  infection  and  toxemia.  As  might 
be  expected,  the  mental  symptoms  belong  to  the  group  of 
dehrium,  confusion  and  stupor.  Delirium  and  active  confusion 
with  hallucinations  are  quite  common.  When  the  confusion  is 
less  active,  it  is  accompanied  by  severe  depression;  often  mis- 
called melancholia.  The  patient  is  dull  and  heavy,  and  suffers 
from  hallucinations  frequently  both  of  hearing  and  of  vision. 
At  times  the  confusion  deepens  into  stupor.  In  other  cases  a 
marked  and  persistent  mental  loss,  a  dementia,  is  established. 
It  is  important  to  add  that  suicide  by  drowning  occurs  in  quite 
a  number  of  cases;  possibly  the  death  by  water  has  its  origin 
in  the  endeavor  of  the  patient  to  seek  relief  from  the  burning 
sensations  caused  by  the  erythema  and  other  lesions  of  the 
skin. 

Rheumatic  Fever. — Rheumatic  fever,  which  must  be  classed 
among  the  infectious  diseases,  may  present,  as  is  well  known, 
delirium  in  its  febrile  period.  Rarely  this  deUrium  is  very- 
active  and  persistent.  More  frequently  a  long-continued 
confusion  with  painful  hallucinations  and  delusions  makes 
its  appearance.  As  in  the  other  infections,  this  disturbance 
comes  on  in  the  postfebrile  or  convalescent  period  of  the  disease. 
The  hallucinations  are  usually  quite  active  and  are  both  auditory 
and  visual.  In  its  general  symptoms  and  character  the  clinical 
picture  does  not  differ  from  that  of  ordinary  confusion.  (See 
Part  I,  Chapter  III.)  It  may  last  a  number  of  weeks.  In  one 
case  under  the  writer's  observation  the  patient  was  for  a  time 
stuporous.  The  prognosis  of  the  mental  symptoms  is,  on  the 
whole,  quite  favorable. 


212  MENTAL    DISEASES 

2.     THE  INTOXICATIONS 

The  mental  disorders  resulting  from  the  various  forms  of 
intoxication  bear  a  general  resemblance  to  each  other.  In  a 
sense,  the  action  of  the  different  poisons  upon  the  cortex  is  the 
same;  the  clinical  pictures,  however,  differ  widely  in  their 
details.  Each  form  of  intoxication  is  distinguished  by  its 
o\\Ti  special  features,  though  in  its  fundamental  characters  it 
resembles  every  other. 

ALCOHOLISM    AND    THE    ALCOHOLIC    INSANITIES 

Alcohol,  the  most  widely  used  of  all  the  poisons,  may,  in  so 
far  as  its  action  upon  the  nervous  system  is  concerned,  be  taken 
as  a  type.  In  general  terms,  its  effects  are  those  of  depression 
of  function,  delirium,  confusion,  and  mental  loss;  i.  e.,  the  dis- 
orders which  it  produces  like  those  which  follow  the  infections 
are  classifiable  imder  the  first  and  fifth  groups;  i.  e.,  delirium, 
confusion,  stupor,  and  dementia. 

When  we  approach  the  subject  of  the  effects  of  alcohol,  we 
are  impressed,  first,  by  the  difference  in  individuals  as  regards 
susceptibihty.  The  degree  of  resistance  to  its  action  may, 
on  the  one  hand,  be  enormous,  and,  on  the  other,  exceedingly 
slight.  Second,  we  learn  that  certain  causes  predispose  to 
its  excessive  use.  Feebleness  of  resistance  may  be  due  to  a 
neuropathy,  a  neurasthenia  or  a  psychasthenia.  Sometimes 
the  neuropathy  is  inherited.  Quite  commonly  we  find  in  the 
family  histories  of  alcoholics  a  record  of  alcoholism,  of  neu- 
rasthenia, or  it  may  be  of  actual  psychoses.  The  inherit- 
ance of  ready  exhaustion,  of  depression,  of  a  neuropathic  make- 
up generally,  undoubtedly  plays  a  role  both  in  the  feebleness 
of  resistance  and  in  the  production  of  the  alcoholic  habit. 
Among  the  causes  leading  to  an  acquired  neuropathy  are  ex- 
hausting illness,  chronic  overwork  and  privation,  or  all  of  these 
causes  variously  combined.     Sometimes  the  habit  has  its  origin 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS      213 

in  the  unhappiness  resulting  from  the  patient  finding  himself 
in  an  occupation  or  calling  to  which  he  is  unsuited  and  in  which 
he  sees  nothing  but  failure.  Frequently,  too,  the  patient 
resorts  to  alcohol  to  aid  him  in  suppressing  a  painful  memory  or 
to  obscure  the  depressing  facts  of  an  existence  alike  intoler- 
able and  unchanging. 

In  many  of  the  cases  of  so-called  hereditary  alcoholism,  the 
neuropathy  that  is  inherited  appears  to  be  a  manic-depressive 
psychosis,  which  manifests  itself  more  particularly  by  a  hypo- 
melancholia,  a  hypomelancholia  with  waves  of  variable  dura- 
tion and  recurrences.  In  other  cases,  again,  the  patient  is 
clearly  in  a  manic  phase— a  hypomania  mild  in  degree — in 
which  the  excitement  and  lack  of  inhibition  are  potent  factors. 
In  other  cases,  again,  there  is  the  common  mode  of  acquisition 
of  the  habit  through  social  custom.  The  habit  is  thus  often 
acquired  in  early  life,  and  may  persist,  as  we  know,  indefinitely; 
but  that  a  pre-existing  or  inherited  neuropathy  exercises  a 
powerful  influence  in  the  production  of  alcoholic  abuse,  is  ex- 
ceedingly probable. 

The  phenomena  of  an  ordinary  attack  of  alcoholic  intoxica- 
tion clearly  illustrate  the  action  of  the  poison.  After  a  given 
amount  of  alcohol,  varying  according  to  the  individual,  has 
been  ingested,  there  ensue  first  the  general  effects  of  stimula- 
tion. The  heart  drives  an  increased  amount  of  blood  through 
the  brain,  and  the  drug  itself  appears  to  have  a  specific  action 
on  the  cortical  neurones  alike  pleasurable  and  exciting.  If  the 
reaction  time  be  tested,  it  is  found  to  be  noticeably  lengthened. 
Very  soon,  too,  especially  if  the  amount  ingested  has  been 
large,  it  is  noted  that  the  individual  has  a  difficulty  both  of 
apprehension  and  comprehension,  and  this  difficulty  is  an  in- 
creasing one.  The  mental  processes  are  distinctly  retarded, 
and  there  is  at  the  same  time  a  diminution  of  inhibition;  there 
is  an  increased  elimination  of  impulses  of  various  kinds.     There 


214  MENTAL    DISEASES 

is  an  increased  flow  of  ideas,  of  ideas  with  motor  elements, 
for  the  patient  is  animated,  gesticulates,  moves  about.  There 
is  also  an  increased  flow  of  words;  the  subject  becomes  talka- 
tive, tells  stories,  becomes  reminiscent,  jests,  puns,  rhymes, 
breaks  into  song.  He  is  buoyant  and  happy,  sad  and  tearful; 
or,  he  is  sexually  excited;  motor  disturbances  become  more 
pronounced  and  exaggerated  gestures,  incoordinated  move- 
ments, language  boastful,  profane,  obscene,  or  maudhn  char- 
acterize the  picture.  The  mental  action  becomes  more  and 
more  disturbed  and  retarded,  apprehension  and  comprehension 
become  more  and  more  obscured,  the  phrases  become  incoherent, 
the  words  mere  jargon,  and  the  patient  finally  lapses  into  un- 
consciousness. 

The  above  picture  outlines,  in  brief,  the  action  of  an  agent 
alike  stimulating  and  depressing.  The  details,  of  course,  vary 
greatly  with  the  personality  of  the  subject.  The  stimulating 
effects  are  short-lived  and  transient  while  the  depression  of 
function  is  more  lasting.  The  stimulating  effects,  as  regards 
the  physical  functions,  more  especially  on  the  circulatory 
apparatus  and  of  small  doses  on  digestion,  cannot,  perhaps,  be 
questioned,  but  there  can  be  no  doubt  that  even  small  doses 
increase  the  difficulty  of  intellectual  labor. 

CHRONIC    ALCOHOLISM 

The  long-continued  excessive  use  of  alcohol  leads  to  certain 
changes  both  mental  and  physical.  The  chronic  alcoholic 
suffers  sooner  or  later  from  a  diminution  of  ability  to  work. 
He  no  longer  has  the  former  capacity  for  continued  applica- 
tion, and,  in  addition,  the  quality  of  his  work  shows  unmistak- 
able deterioration.  He  also  finds  it  difficult  and  later  impossible 
to  take  up  new  subjects,  new  ideas,  or  to  learn  new  methods. 
His  mental  horizon  becomes  narrowed  and  contracted.  He 
remains  in  his  accustomed  channels  of  thought  and  action. 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     215 

He  learns  with  difficulty,  forgets  readily.  His  memory  and 
judgment  alike  become  impaired.  He  invariably  fails  to  realize 
his  own  condition.  The  admonitions  of  relatives  and  friends  are 
misunderstood  and  finally  resented.  He  denies  that  he  is 
drinking  or  that  he  is  drinking  too  much.  He  is  drinking  just 
what  is  right;  no  one  need  tell  him,  he  knows;  others  should 
mind  their  own  business,  etc.,  etc.  Soon  he  develops  ideas  of 
being  injured,  unduly  interfered  with,  annoyed,  oppressed, 
and  even  persecuted  by  those  about  him.  He  is  emotionally 
irritable,  restless,  and  unreliable.  He  forgets  his  engagements 
or  is  so  intoxicated  that  he  is  unable  to  fulfil  them.  He  loses 
his  sense  of  the  proprieties  and  decencies.  Shame,  sense  of 
duty,  and  obfigation  alike  become  blunted.  Love  of  wife, 
child,  or  parent  gives  place  to  indifference,  to  neglect,  or,  it 
may  be,  to  dislike.  The  mental  impairment  becomes  general, 
and  the  patient  may  remain  in  this  condition,  sometimes  better, 
sometimes  worse,  for  years.  In  some  cases  the  deterioration 
is  progressive.  The  sense  of  injury  grows  more  marked  and 
may  assume  the  form  of  veritable  delusions;  it  may  even  be 
compficated  by  hallucinations.  Frank  mental  disease  may 
thus  be  established,  and  this  may  finally  pass  into  a  true  de- 
mentia. However,  this  is  the  exception;  by  far  the  larger 
number  of  cases  of  chronic  alcoholism  remain  in  a  condition 
of  partial  impairment  only,  and  are  mentally  preserved  to  such 
a  degree  that  their  restraint  on  the  ground  of  insanity  is  im- 
possible. They  are  not  insane  in  the  legal  sense;  merely  the 
sufferers  from  a  vicious  habit.  It  is  this  fact  which  renders 
the  care  of  such  patients  one  of  extreme  difficulty. 

The  psychic  phenomena  of  chronic  alcoholism  are,  as  is  well 
knoMTi,  accompanied  by  visceral  changes  no  less  pronounced. 
Space  will  not  permit  us  to  discuss  these  in  detail.  They 
involve  the  circulatory  apparatus,  the  digestive  tract,  the  vari- 
ous glands,  the  brain,  and  peripheral  nerves.     The  heart  is 


216  MENTAL    DISEASES 

weak,  fatty,  readily  dilated;  the  pulse  soft  and  compressible; 
the  peripheral  vessels  dilated,  as  witness  the  lividity  and  chronic 
turgescence  of  the  features  of  the  chronic  alcoholic.  There 
is  chronic  gastric  catarrh;  the  early  morning  vomiting  of  the 
chronic  alcoholic  is  a  familiar  picture.  The  liver  reveals 
cirrhosis  in  greater  or  less  degree;  there  is  also  a  nephritis  more 
or  less  advanced. 

The  patient  sleeps  but  little.  He  complains  of  headache, 
especially  in  the  mornings;  there  is  dizziness,  tremor  of  the 
tongue  and  hands,  weakness  of  the  legs,  wasting  of  the  muscles, 
blunting  of  sensation,  pain,  peripheral  neuritis.  There  is 
usually  also  a  more  or  less  marked  degree  of  amblyopia;  fre- 
quently optic  neuritis  and  atrophy.  Not  infrequently,  also, 
the  picture  is  complicated  by  epilepsy. 

The  forms  of  frank  mental  disease  which  result  from  alcohol 
consist  of  alcoholic  delirium  (delirium  tremens),  alcoholic  con- 
fusion, alcoholic  dementia.  It  is  to  alcoholic  delirium  that  we 
will  first  turn  our  attention. 

ALCOHOLIC  DELIRIUM 
(Delirium  Tremens) 
Alcoholic  delirimn  ordinarily  occurs  in  a  person  already  ad- 
dicted to  alcohol.  An  unwonted  excess,  in  which  the  usual 
amounts  are  greatly  exceeded,  may  be  the  direct  exciting  cause; 
on  the  other  hand,  the  sudden  withdrawal  of  the  accustomed 
stimulant  may  lead  directly  to  the  outbreak  of  symptoms. 
Alcoholic  subjects,  also,  are  exceedingly  vulnerable  to  shock, 
and  a  trauma,  such  as  a  broken  leg,  a  severe  fall,  sudden  fright, 
sudden  fatigue,  may  prove  an  exciting  cause.  It  is  knoA^m  also 
that  such  persons  become  dehrious  rather  readily  when  they 
are  attacked  by  some  infection,  such  as  pneumonia,  erysipelas, 
rheumatism.  That  an  alcoholic  or  neuropathic  heredity  pre- 
disposes to  the  attacks  is,  of  course,  to  be  expected. 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS      217 

Frequently  prodromata  are  observed  extending  over  several 
days,  sometimes  a  week  or  longer.  The  patient  is  irritable, 
depressed,  and  nervous,  starting  at  the  least  sound.  He  has 
precordial  distress,  headache,  dizziness,  and  sleeplessness. 
When  sleep  does  occur  it  is  for  short  periods  only,  and  is  dis- 
turbed by  dreams  and  nightmares.  His  hands,  his  lips, 
his  tongue  tremble  more  than  ever;  even  his  speech  may  be 
disturbed.     Finally,   the  delirium  supervenes. 

This  delirium  presents  the  symptom  group  common  to  all  of 
the  deliria  (see  pp.  34,  et  seq.).  It  is  exceedingly  active,  and  is 
characterized  by  the  fact  that  hallucinations  of  vision  are  ex- 
ceedingly prominent.  Hallucinations  of  hearing,  and  appar- 
ently of  the  other  senses,  are  also  present,  but  the  hallucinations 
of  vision  are  very  numerous,  appear  to  be  very  vivid,  terrifying, 
and  phantastic.  The  patient  sees  serpents,  frightful  crea- 
tures, ominous  and  threatening.  The  auditory  hallucinations 
are  alike  painful,  while  the  delusive  ideas,  as  betrayed  by  the 
speech  and  action  of  the  patient,  are  equally  terrible  and  dis- 
tressing, and  fully  justify  the  expression  of  ''the  horrors" 
often  appUed  by  lay  persons  to  the  condition.  The  patient 
is  very  restless,  struggles  with  or  tries  to  escape  from  his  ene- 
mies. A  coarse  tremor  involves  not  only  the  face,  tongue,  and 
hands,  but  also  the  limbs  and  trunk.  The  confusion  is  pro- 
found, the  patient  has  numerous  illusions  of  the  persons  and 
objects  about  him  which  add  to  his  terror.  Sometimes,  again, 
he  seems  to  be  entirely  oblivious  to  his  environment.  Con- 
sciousness is  in  such  case  greatly  obscured;  at  other  times  the 
patient  can  be  recalled  to  himself  for  short  periods  of  time  and 
by  persistent  effort.  Sleep  is  practically  abolished  unless 
secured  by  medicinal  means.  Sometimes,  too,  muscular 
twitchings  or  frank  convulsive  seizures  are  added  to  the  picture. 
The  general  physical  condition  is  one  of  exhaustion.     The  face 


218  MENTAL    DISEASES 

is  relaxed,  the  tongue  heavily  coated,  the  lips  and  teeth  covered 
with  sordes.  The  body  is  covered  with  a  sticky  sweat;  the 
pulse  is  small,  feeble,  accelerated,  and  sometimes  irregular; 
the  heart's  action  is  weak.  The  temperature  is  normal  unless 
compUcations,  such  as  bronchitis,  nephritis,  or  pneumonia,  are 
present.  The  urine  is  usually  much  diminished  in  amount 
and  concentrated. 

The  duration  of  an  attack  of  delirium  tremens  may  be  very 
short;  e.  g.,  twenty-four  to  forty-eight  hours;  more  frequently 
it  extends  over  several  days,  and  sometimes  persists  in  a  less 
active  form  for  a  week  or  more.  Not  infrequently  it  subsides 
after  a  sound  sleep.  Sometimes  the  active  delirimn  grows  less 
but  the  attack  does  not  disappear,  and  the  patient  passes  into 
a  more  or  less  prolonged  period  of  confusion. 

The  great  majority  of  cases  recover,  though  now  and  then 
death  occurs  from  exhaustion,  from  pneumonia,  from  nephritis, 
or  from  failure  of  the  overtaxed  and  dilated  heart. 

ALCOHOLIC    CONFUSION 
(Alcoholic  Confusional  Insanity) 

Alcoholic  confusion  may  present  itself  in  two  forms:  first, 
in  the  form  of  a  confusion  not  differing  in  its  symptoms  from 
that  of  confusion  in  general,  and,  second,  in  a  form  in  which 
the  delusions  assume  a  paranoid  character. 

The  first  form  may  have  its  origin  in  an  attack  of  delirium 
tremens  which  has  not  entirely  subsided,  and  which  has  passed 
into  a  more  or  less  persistent  confusion.  Not  infrequently 
this  is  the  case  when  the  patient  has  suffered  from  repeated 
attacks  of  alcoholic  delirium.  In  other  cases,  again,  the  con- 
fusion makes  its  appearance  without  a  preceding  delirium;  thus 
a  chronic  alcoholic  suffers  more  than  usually  from  headaches, 
more  than  usually  from  insomnia.     He  is  more  irritable  than 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS      219 

before;  he  is  more  nervous,  fearful,  and  depressed,  and  his 
mental  operations  are  more  difficult.  Gradually,  though  some- 
times rapidly,  hallucinations  make  their  appearance  and  with 
them  terrifying  delusions.  The  picture  presented  is  that  of 
an  active  confusion  which  never  attains  the  height  of  a  delirium. 
The  visual  hallucinations  may  be  less  prominent;  it  is  the  audi- 
tory hallucinations  which  are  especially  marked.  They  are, 
as  in  the  dehrium,  painful  and  distressing.  The  confusion 
gradually  becomes  less  active  and  persists  in  a  subacute  form 
for  a  long  time,  usually  for  many  months.  As  a  rule,  it  finally 
subsides,  though  it  leaves  the  patient  quite  frequently  with  some 
mental  impairment.  Occasionally  it  terminates  in  a  more  or 
less  marked  dementia.  However,  especially  in  the  younger  in- 
dividuals, the  recovery  from  the  attack  may  be  remarkably 
good,  the  patient  becoming  to  all  intents  and  purposes  well. 

The  prognosis  of  an  attack  of  alcoholic  confusional  insanity 
is  bad  in  proportion  to  the  degree  and  duration  of  the  preceding 
alcoholism  and  the  age  of  the  patient.  The  presence  of  chronic 
alcohohc  changes  in  the  tissues  is  here  a  factor  of  moment. 
If  the  preceding  alcoholism  has  not  been  of  long  duration, 
if  tissue  changes  have  not  yet  become  established,  and  if  the 
patient  is  still  relatively  young,  has  not  yet  attained  middle 
age  or  the  senile  period,  the  degree  of  recovery  that  may  ensue 
is  sometimes  very  great. 

In  connection  with  alcoholic  multiple  neuritis,  Korsakow 
many  years  ago  described  a  condition  of  confusion  which  was 
characterized,  especially  by  fictitious  memories,  by  a  marked 
tendency  to  the  fabrication  of  events  and  occurrences  of  all 
kinds.  There  is  here  a  general  impairment  of  memory,  and 
apparently  there  are  gross  lacunar  defects  which  are  filled  in 
automatically  and  spontaneously  by  the  patient.  This  con- 
dition is  not  necessarily  associated  with  multiple  neuritis,  but 


220  MENTAL    DISEASES 

may  exist  in  the  absence  of  the  latter.  The  so-called  Korsa- 
kow's  psychosis  may  have  its  origin  in  the  course  of  an  ordinary 
alcoholic  confusion.  Frequently  it  occurs  after  the  latter  has 
existed  for  some  time;  in  other  cases  it  occurs  after  alcoholic 
neuritis  has  been  estabhshed  for  some  time.  There  is  no  good 
reason  for  regarding  it  other  than  an  alcohoUc,  i.  e.,  a  toxic, 
post-alcoholic,  confusion, 

ALCOHOLIC    PARANOIA 

As  already  pointed  out  in  the  consideration  of  chronic  alco- 
hoUsm,  the  patient  suffering  from  chronic  alcoholism  not  in- 
frequently develops  a  sense  of  injury,  a  feeling  that  the  persons 
who  are  about  him  and  who  quite  naturally  admonish,  chide, 
and  try  to  influence  or  restrain  him,  are  opposed  to  him,  are 
unfriendly.  Finally,  true  persecutory  ideas  may  develop  and 
not  infrequently  the  picture  of  a  paranoia  is  presented.  It  is 
exceedingly  probable,  however,  that  a  paranoia  does  not  de- 
velop save  in  a  predisposed  subject;  i.  e.,  in  a  patient  who  al- 
ready has  the  paranoiac  make-up  or  constitution.  Again, 
there  is  danger  here  also  of  confusing  with  alcoholism  a  paranoia 
which  has  existed  previously,  and  in  which  the  picture  pre- 
sented by  the  paranoiac  has  been  modified  by  a  subsequently 
acquired  alcoholism.  Under  any  circumstances  the  paranoid 
nature  of  the  symptoms  is  very  striking.  The  patient  suffers 
from  numerous  hallucinations  of  hearing,  vision,  taste,  smell, 
and  of  bodily  and  visceral  sensations.  At  the  same  time,  de- 
lusions of  persecution  make  their  appearance.  The  patient 
may,  as  in  ordinary  paranoia,  speak  of  holes  in  thfe  wall,  of  the 
house  being  wired,  of  his  being  annoyed  and  persecuted  in 
various  ways.  Quite  frequently  he  believes  that  there  is 
poison  in  his  food,  that  poisonous  gases,  foul  smells,  and 
stenches  are  in  some  way  put  into  his  room. 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS       221 

There  is  one  delusion,  however,  that  occurs  in  alcohohc 
paranoia  with  great  frequency,  and  which,  when  met  with,  is 
looked  upon  as  of  almost  diagnostic  import,  and  that  is  the 
delusion  of  marital  infidelity.  Sooner  or  later  the  husband 
believes  that  his  wife  is  unfaithful,  and  at  times  this  conviction 
becomes  so  powerful  that  it  leads  to  homicide;  it  is  the  wife, 
however,  and  not  the  supposed  paramour,  who  is  slain.  Indeed, 
the  patient's  notion  as  to  the  persons  with  whom  his  wife  is 
having  improper  relations  is  usually  very  vague.  He  commonly 
speaks  of  them  as  "men,"  less  frequently  by  name  or  other 
distinctive  designation. 

The  frequency  of  the  delusion  of  marital  infidelity  is  such 
as  to  suggest  that  there  are  special  reasons  for  its  appearance. 
The  truth  probably  lies  in  the  fact,  first,  that  the  alcoholic 
suffers  from  a  depression  of  his  sexual  function,  which  becomes 
more  marked  in  proportion  to  the  degree  and  the  duration  of 
the  alcoholic  poisoning.  He  becomes  both  indifferent  and 
more  or  less  incompetent.  Further,  the  chronic  alcoholic, 
bestialized  and  brutal,  is  hardly  received  willingly  by  the  wife; 
indeed,  the  latter  frequently,  upon  some  pretext  or  other, 
denies  her  husband,  avoids  an  act,  the  consequences  of  which 
may  only  add  to  the  misery  and  unhappiness  of  a  situation 
already  difficult  to  bear.  In  addition,  we  must  remember  that 
the  attitude  of  the  wife,  because  of  her  constant  remonstrances, 
pleadings,  and  reproaches,  is  already  construed  as  inimical. 
It  is  hardly  surprising,  therefore,  that  the  patient  sooner  or 
later  conceives  the  idea  that  his  wife  has  other  lovers.  Fre- 
quently, too,  he  combines  this  idea  with  the  belief  that  she  is 
trying  to  get  rid  of  him  and  is  putting  poison  in  his  food.  His 
statements  in  this  respect  are  usually  such  as  to  leave  no  doubt 
that  he  is  suffering  from  marked  hallucinations  and  illusions 
of  taste.     Associated  with  these  there  may  be  vivid  hallucina- 


222  MENTAL    DISEASES 

tions  of  sight  and  hearing.  He  may  see  men  hovering  or  con- 
cealed about  the  house  or  may  hear  their  footsteps,  signals, 
or  messages.  He  may  search  for  them  at  night,  candle  in 
hand,  under  the  bed  and  in  the  closets. 

As  in  ordinary  paranoia,  the  patient's  orientation,  his  general 
appreciation  of  his  environment,  may  be  unimpaired,  and  in 
his  relations  with  others  than  the  members  of  his  family  or 
those  with  whom  he  comes  in  immediate  contact  he  may  betray 
little  of  his  really  serious  condition.  Later,  however,  reticence 
and  restraint  give  way,  and  he  talks  freely  and  insistently  of 
his  troubles.  His  sleep  is  of  course  greatly  disturbed,  his 
bodily  nutrition  fails,  and  he  loses  in  weight.  At  the  same  time 
he  may  not,  and  frequently  does  not,  present  the  gross  physical 
signs  of  alcoholism  to  the  degree  in  which  they  are  found  in 
other  alcoholic  patients.  Again,  the  withdrawal  of  alcohol  is 
not  followed  by  the  disappearance  of  the  delusions.  As  in 
ordinary  paranoia,  the  latter  are  fixed  and  persistent.  Long 
after  the  patient,  as  in  the  prison  or  the  asylum,  has  had  no 
access  to  alcohol,  the  belief  in  the  unfaithfulness  of  the  wife 
and  that  she  tried  to  poison  him  remains  unshaken.  As 
the  case  continues,  expansion  may  become  manifest.  He 
conceives  the  idea  that  he  has  never  been  properly  appreciated 
or  understood,  that  he  has  never  had  a  chance,  that  he  is  really 
very  able,  that  he  is  really  a  person  of  consequence  and  im- 
portance. Rarely,  however,  do  his  ideas  assume  a  definite 
form,  as  in  ordinary  paranoia.  On  the  whole,  expansion  in 
alcoholic  paranoia  is  neither  marked  nor  characteristic. 

The  prognosis  of  an  alcoholic  paranoia  is  very  unfavorable. 
The  physical  signs,  due  to  the  chronic  intoxication,  may  of 
course  become  less  marked,  and  the  general  health  may  im- 
prove under  institution  care,  but,  as  already  stated,  the  para- 
noid ideas  and  attitude  persist. 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS      223 
ALCOHOLIC    DEMENTIA 

Mental  impairment,  more  or  less  marked  in  degree,  may  be 
the  result  of  long-continued  chronic  alcoholism,  may  ensue 
after  severe  and  repeated  attacks  of  alcoholic  delirium,  or  after 
a  prolonged  attack  of  alcoholic  confusion.  As  in  other  forms 
of  dementia,  there  is  loss  of  memory  and  an  impairment  of  the 
mental  faculties  generally.  The  blunting  of  the  finer  feelings, 
the  sense  of  shame,  of  the  proprieties,  of  the  affections,  already 
present  in  the  chronic  alcoholic,  is  more  pronounced  here.  If 
it  comes  on  in  the  course  of  chronic  alcoholism  it  is  progressive; 
hallucinations,  confusion,  delusive  ideas  complicate  the  picture. 
The  deterioration  gradually  becomes  more  and  more  pronounced. 
As  in  dementia  from  other  causes,  the  loss  of  memory  grows 
deeper,  until  it  involves  all  periods  of  the  patient's  life.  Loss 
of  will  and  loss  of  self-control  are  progressive.  The  patient 
is  indifferent  to  his  person,  soils  himself.  Incoherence,  paucity 
and  feebleness  of  thought,  and,  finally,  mindlessness,  and,  it 
may  be,  stupor,  complete  the  picture. 

That  this  picture  should  suggest  paresis,  or,  when  occurring 
in  older  individuals,  should  suggest  senile  dementia,  is  not  sur- 
prising. From  paresis  the  history  of  the  case  and  the  absence 
of  the  physical  signs — i.  e.,  of  the  Argyll-Robertson  pupil,  of 
inequality  of  pupils,  of  tremor  of  the  lips  and  tongue,  of  the 
atactic  speech,  of  the  anomalies  of  the  tendon  reactions — serve 
to  make  the  distinction.  A  serological  examination  of  the  blood 
and  cerebrospinal  fluid  may  also  be  made  (see  section  on  Paresis) , 
though  the  clinical  examination,  as  a  rule,  abundantly  suffices. 
The  distinction  from  senile  dementia  and  from  dementia  due 
to  other  causes  is  again  to  be  based  upon  the  history  and  upon  the 
very  evident  signs  of  alcoholism  and  associated  visceral  sjnmp- 
toms.  In  practice  but  Httle  difficulty  is  experienced.  It  was 
at  one  time  the  habit  to  speak  loosely  of  alcoholic  dementia  as 


224  MENTAL    DISEASES 

alcoholic  paresis,  but  the  expression  is  misleading  and  has  no 
justification. 

A  correct  diagnosis  is  important,  because  alcoholic  dementia 
presents  in  some  cases  a  favorable  prognosis.  Nature  is  very- 
kind,  and  it  is  remarkable  how  great  a  degree  of  recovery 
sometimes  ensues  in  an  apparently  hopeless  case  after  the  alco- 
hol has  been  long  discontinued.  Indeed  it  may  be  said  in 
general  that,  if  the  visceral  changes  are  not  pronounced,  some 
degree  of  recovery  may  usually  be  expected.  Sometimes  this 
is  decided  and  may  approximate  the  normal;  in  other  cases, 
again,  a  persistent  mental  impairment,  a  feebleness  of  memory, 
and  inability  for  sustained  mental  effort  remain.  In  others, 
again,  there  may  be  a  tendency  to  mild  confusion  from  slight  ex- 
haustion, and,  perhaps,  to  a  persistence  of  auditor}^  hallucina- 
tions. In  the  unfavorable  cases,  cases  in  which  permanent 
damage  has  been  done  to  the  viscera,  and  especially  to  the 
blood-vessels  and  membranes  of  the  brain  and  to  the  brain 
tissue  itself,  little  or  no  improvement  may  ensue  and  the  de- 
mentia may  persist  in  a  profound  degree  until  death. 

PLUMBISM    AND    THE    INSANITIES    DUE    TO    LEAD 

Chronic  lead  poisoning,  like  alcoholic  poisoning,  induces  dis- 
turbances of  function  belonging  to  the  first  and  fifth  groups  of 
our  classification.  Lead  poisoning  is  not  met  with  as  frequently 
in  the  public  clinics  as  formerly,  and  this  is  also  true  of  the  cases 
observed  in  private  practice.  It  is  also  a  remarkable  fact  that, 
of  the  cases  of  lead  poisoning  considered  as  a  whole,  the  lead 
insanities  form  but  a  small  percentage.  Lead  insanities  are, 
therefore,  rare.  They  are  very  interesting,  however,  because 
of  the  analogies  and  resemblances  which  they  bear  to  the  alco- 
holic insanities,  and  because  they  illustrate  the  general  truth, 
already  pointed  out,  that  there  is  a  general  identity  of  action 
of  the  various  poisons.     Lead  poisoning  affects  the  organism  as 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     225 

a  whole,  but,  as  is  well  known,  it  usually  assumes  well-marked 
clinical  forms;  namely,  that  of  lead  colic,  lead  paralysis  with 
its  double  wrist  drop,  lead  rheumatism  or  arthralgia,  and  lead 
encephalopathy.  Occasionally  the  toxic  effects  remain  general, 
and  there  is  then  a  symptom  group  presented  suggesting  a, 
peripheral  tabes,  i.  e.,  a  widely  diffused  peripheral  neuritis  with 
changes  in  the  optic  nerves;  one  such  case  has  been  observed 
by  the  writer;  in  another  case  of  general  lead  poisoning  the 
patient  presented  a  hysteroneurasthenic  symptom-group  with- 
out definite  physical  signs.  Cases  with  diffuse  and  general 
symptoms  only  are,  however,  exceedingly  rare,  but  they  serve 
to  accentuate  the  fact  of  the  general  toxic  action  of  the  lead, 
an  action  which  is  probably  present  in  the  classical  clinical 
forms,  but  does  not  usually  attract  attention,  or  at  least  is  not 
usually  sought  for. 

Lead  insanities,  in  such  cases  as  the  writer  has  observed, 
are  not  attended  by  lead  palsies  and  lead  colic,  though  some- 
times a  history  of  lead  colic  can  be  elicited.  It  would  seem  as 
though  the  insanity  in  a  given  case  were  the  result  of  the  gen- 
eral lead  toxemia,  though  a  local  effect  upon  the  brain,  its 
vessels  and  membranes,  cannot  be  excluded. 

The  mental  disorder  most  frequently  observed  is  that  of  de- 
lirium. As  a  rule,  it  is  preceded  by  headache,  marked  insomnia, 
and  frightful  dreams.  Tinnitus,  flashes  of  light,  slowness  of 
mental  action,  and  depression  also  make  their  appearance. 
Finally,  delirium  sets  in  and  may  be  intense  in  degree.  The  hal- 
lucinations are  exceedingly  painful  and  terrifying,  and,  very 
curiously,  as  in  alcoholic  delirium,  visual  hallucinations  pre- 
dominate. The  patient  sees  terrible  and  menacing  forms  and 
objects.  The  resemblance  to  delirium  tremens  is  still  further 
increased  by  the  presence  of  tremor,  which  may  be  very 
marked.     The  restlessness  is  very  great  and  severe  exhaus- 

15 


226  MENTAL    DISEASES 

tion  may  occur.  Sometimes  stupor  and  coma  supervene. 
At  times  epileptiform  convulsions  make  their  appearance. 
It  is  rather  suggestive,  also,  that  amaurosis  not  infrequently 
follows  an  attack  of  lead  delirium,  and  the  query  arises  whether 
the  visual  hallucinations  bear  any  relation  to  the  changes  in 
the  optic  nerve.  The  urine  is  usually  scanty  and  concentrated 
and  may  contain  albumin. 

The  delirium  may  last  for  several  days,  rarely  does  it  extend 
over  a  week  or  two.  Sometimes  its  progress  is  interrupted; 
at  times  there  are  remissions  followed  by  recurrences.  In  cases 
in  which  the  intoxication  has  not  been  profound,  recovery  ensues; 
in  other  cases  a  fatal  termination  is  not  unusual;  this  result 
followed  in  three  of  the  cases  under  the  writer's  observation. 

Chronic  lead  poisoning  may  lead  to  symptoms  less  acute  in 
character.  There  may  be  mental  depression  vnih  mental 
weakness,  featured  now  and  then  by  confusion,  episodes  of 
delirium,  or  epileptiform  attacks.  In  one  instance  observed  by 
the  writer,  in  which  both  auditory  and  visual  hallucinations 
were  prominent,  the  delusions  assumed  a  distinctly  paranoid 
character;  the  patient  was  persecutory  as  regards  his  family 
and  made  charges  against  the  chastity  of  his  wife.  There  was 
here  a  suggestive  resemblance  to  alcoholic  paranoia.  Such 
cases  must  be  regarded  as  excessively  rare. 

In  another  group  of  cases,  the  lead  poisoning  results  in  a 
dementia.  Thus,  dementia  may  supervene  upon  an  attack 
of  lead  delirium  or  may  follow  a  more  or  less  prolonged  and 
chronic  lead  poisoning,  in  which  the  history  of  delirious  episodes 
and  epileptic  seizures  is  not  infrequent.  The  symptom-group 
is  that  of  dementia  ordinarily.  There  is  a  more  or  less  grave 
impairment  of  memory  and  of  the  other  mental  faculties;  a 
progressive  deterioration  of  habits  and  conduct,  of  "s\all-power, 
self-control,  speech  and  thought,  until  a  decided  or  profound 
mental  loss  is  estabUshed. 


MENTAL    DISEASE    RELATED   TO    SOMATIC    AFFECTIONS     227 

Lead  dementia  offers  in  some  cases  a  favorable  prognosis; 
favorable  provided  the  intoxication  has  not  been  too  long  con- 
tinued. In  this  respect  it  resembles  alcohol.  If  the  poisoning 
has  been  long  continued,  however,  and  if  there  be  reason  to 
think  that  organic  changes,  as  instanced  by  degeneration  of 
the  optic  nerve,  have  supervened  in  the  nerve-centers,  the 
prognosis  is  proportionately  unfavorable.  On  the  whole,  the 
prognosis  of  lead  dementia  is  much  more  unfavorable  than 
that  of  alcohohc  dementia. 

MORPHINISM 
The  habit  of  using  opium  or  morphia  has  its  origin  mainly 
in  the  employment  of  the  drug  for  the  relief  of  pain.  The 
vicious  practice  of  opium  smoking  brings  to  our  hospitals  and 
clinics  but  few  patients;  occasionally,  however,  we  find  in  the 
prisons  persons  who  have  been  opium  smokers,  and  who,  de- 
prived of  the  drug  by  reason  of  their  confinement,  usually  suffer 
very  keenly,  especially  at  first.  Ordinarily,  however,  the  habit 
is  acquired,  as  just  stated,  in  the  use  of  the  drug  for  the  rehef 
of  pain.  That  laudammi  or  that  paregoric  will  stop  pain  is 
known  to  every  layman,  and  that  some  persons  should  have 
recourse  to  them  now  and  then,  or  perhaps  habitually,  is  not 
surprising.  Women  suffering  from  pain  at  the  menstrual 
epoch,  and  finding  that  a  few  drops  of  laudanum  or  a  few  tea- 
spoonfuls  of  paregoric  give  relief,  may  gradually  get  into  the 
habit  of  using  these  medicines  regularly  at  the  menstrual  peri- 
ods; little  by  little  the  the  patient  begins  to  use  them  also  in 
the  intervals  on  some  pretext  or  other;  she  feels  weak,  cannot 
do  her  work,  feels  a  craving  for  the  drug,  and  thus  gradually 
the  habit  of  taking  laudanum  or  paregoric  is  established. 
Much  more  frequently,  the  patient  is  one  who  has  experienced 
the  prompt  and  pleasurable  rehef  given  by  a  hypodermic  in- 
jection of  morphia.     The  physician  is  sent  for  again  and  per- 


228  MENTAL    DISEASES 

haps  repeatedly.  The  latter,  knowing  the  danger  of  the  for- 
mation of  a  habit,  finally  cautions  the  patient,  refuses  to  com- 
ply, and  insists  that  the  pain,  if  present,  be  relieved  by  other 
means.  Under  these  circumstances  the  patient  frequently 
succeeds  in  securing  a  syringe  and  also  a  supply  of  the  drug. 
Tolerance  is  quickly  established,  and  the  dose  is  rapidly  in- 
creased until  very  large  amounts  may  be  taken — ten,  twelve 
or  more  grains  in  the  twenty-four  hours.  It  is  very  difficult 
to  get  accurate  information  as  to  the  amounts;  patients  habit- 
ually understate  it,  and  frequently  they  do  not  know  how 
much  they  take.  Sometimes  they  procure  it,  not  in  the  form  of 
tablets,  but  in  dram  bottles  of  the  powder,  and  freely  help 
themselves. 

It  should  be  added  that,  as  in  the  case  of  alcohol,  the  forma- 
tion of  the  habit  is  greatly  favored  by  the  existence  of  depres- 
sion or  of  recurrent  depressed  mental  states.  In  many  pa- 
tients there  is  a  frank  neuropathy.  We  must  remember  that 
in  the  normal  individual  there  is  little  risk  in  the  production 
of  a  habit  when  the  drug  is  administered  by  a  physician.  The 
normal  individual,  having  been  reUeved  of  his  pain,  has  no  de- 
sire for  a  repetition  of  the  dose. 

The  symptoms  of  chronic  morphia  poisoning  are  both  mental 
and  physical.  The  patient  betrays  a  loss  of  vigor,  an  im- 
pairment of  the  power  to  do  his  work;  his  energy  and  apti- 
tude alike  are  diminished.  His  will-power  is  lessened  and  in 
his  thoughts  and  acts  he  reveals  indifference.  His  emotions 
become  blunted  and  there  is  a  loss  of  the  sense  of  responsibility. 
His  character  undergoes  marked  deterioration.  He  does  not 
hesitate  to  lie,  to  practice  deception,  especially  if  by  the  latter 
he  can  secure  a  supply  of  his  coveted  stimulant;  nor  does  he 
hesitate  to  commit  theft  if  it  enable  him  to  achieve  this  object. 

The  memory  likewise  becomes  impaired  and  the  intellectual 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS      229 

faculties,  as  a  whole,  betray  a  depression  of  function.  There 
is  inertia  and  torpor,  which  may  be  very  marked;  at  the  same 
time  the  patient  is  irritable,  especially  during  the  intervals 
between  the  doses  of  his  drug  or  when  he  has  been  deprived 
of  it  for  a  longer  period  than  usual.  Finally,  his  sleep  is 
much  impaired;  quite  commonly  he  cannot  sleep  until  he  has 
had  his  morphia.  Frequently,  too,  he  is  hallucinatory  while 
the  sleep  is  coming  on. 

When,  in  making  a  physical  examination,  we  handle  the  limbs 
of  the  patient,  we  note  that  he  flinches;  there  is  a  more  or  less 
marked  hyperesthesia  of  the  skin  of  the  extremities.  Some- 
times the  patient  describes  paresthesias;  more  rarely  does  the 
normal  sensibility  seem  to  be  diminished.  There  is  marked 
muscular  weakness,  together  with  tremor  and  loss  of  tone. 
The  reflexes  betray  no  characteristic  change;  sometimes  they 
are  exaggerated,  especially  during  the  nervous  and  excited 
periods;  sometimes  they  are  diminished. 

The  nutrition  of  the  patient  is  greatly  impaired.  The  super- 
ficial fat  disappears;  the  skin  is  yellow,  relaxed,  and  dry. 
Sometimes,  when  the  drug  has  been  used  for  many  years,  the 
appearance  and  the  mental  state  suggest  that  of  a  person  who 
is  aging  prematurely.  If  we  examine  the  skin  closely,  we  often 
find  numerous  fine  scars  of  hypodermic  injections;  sometimes 
the  scars  of  pustules,  local  suppuration  from  infected  injections, 
or  furuncles  may  be  noted. 

The  mouth  and  throat  are  dry.  The  tongue  is  frequently 
coated.  The  appetite  is  greatly  diminished;  especially  is  there 
a  dislike  for  meats.  Digestion  is  delayed  and  there  is  marked 
constipation.  The  circulation  is  much  depressed;  cardiac 
asthenia  is  marked,  and,  not  infrequently,  the  patient  suffers 
from  palpitation.  The  extremities  are  cold.  There  is  a  greatly 
diminished  thirst  and  the  urine  is  much  diminished  in  amount. 


230  MENTAL    DISEASES 

Menstruation  may  become  scanty  or  may  be  suspended.  If 
the  use  of  the  drug  continues  for  a  long  time,  weakness  and 
exhaustion  may  become  profound  and  death  may  ensue,  either 
from  some  visceral  complication,  such  as  a  gastro-intestinal 
disturbance,  a  diarrhea,  a  dysentery,  or  some  infection  of  the 
respiratory  tract,  or,  it  may  be,  from  heart  failure. 

Very  interesting  and  very  important  symptoms  ensue  in  a 
case  of  morphia  habit  when  the  poison  is  withdrawn.  These 
vary  greatly  in  accordance  with  the  gradual  or  abrupt  character 
of  the  withdrawal.  The  special  point  of  importance  to  bear 
in  mind  is  that  they  are  never  absent  if  withdrawal  of  the  poison 
is  actually  being  accomplished.  It  is  the  custom  of  the  writer, 
for  reasons  which  will  soon  become  apparent,  to  withdraw  the 
drug  gradually,  i.  e.,  by  a  progressive  diminution  of  the  dose. 
Just  as  soon  as  the  amount  given  falls  below  that  to  which  the 
patient  is  accustomed,  restlessness  makes  its  appearance.  This 
restlessness  may  become  very  marked,  and  is  always  accom- 
panied by  more  or  less  insomnia.  The  patient  also  yawns  a 
great  deal  or  sneezes,  complains  perhaps  of  having  caught 
cold,  or  perhaps  has  an  attack  of  difficult  respiration,  simulating 
asthma.  In  addition  to  restlessness,  the  patient  manifests 
signs  of  fear,  complains  of  a  sense  of  oppression,  declares  him- 
self dissatisfied  with  the  treatment  and  insists  upon  going  home. 
Involuntary  movements  of  the  legs  and  arms  also  make  their 
appearance,  the  limbs  being  thrown  about  the  bed.  At  times 
this  is  merely  due  to  restlessness;  at  other  times  distinct  in- 
voluntary jerkings  make  their  appearance.  Intention  tremor 
also  becomes  evident.  When,  for  instance,  the  patient  at- 
tempts to  pick  up  a  glass  of  water  it  is  noticed  that  he  trembles 
decidedly.  Sometimes,  instead  of  an  asthmatic  attack,  all  the 
symptoms  referable  to  a  cold  in  the  head  or  a  spasmodic  cough 
may  make  their  appearance.     Sometimes  vesical  tenesmus  is 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     231 

noted.  Palpitation  of  the  heart  may  also  be  evident,  or  the 
patient  may  complain  of  fluttering  sensations  in  the  pre- 
cordia. 

If  the  withdrawal  be  abrupt  and  complete,  there  appears, 
after  a  few  hours,  a  feeling  of  great  weakness  and  fatigue. 
The  patient  is  unable  to  stand  or  to  move  about.  He  trembles 
from  exhaustion  and  his  body  is  bathed  in  sweat.  There  is  a 
sense  of  sinking  and  oppression  in  the  epigastrium,  and  very 
frequently  gastric  and  abdominal  pains,  accompanied  by  nau- 
sea, vomiting,  and  profuse  diarrhea.  The  heart's  action 
becomes  weak,  the  pulse  rapid,  the  extremities  cold.  The  pa- 
tient is  greatly  agitated  and  disturbed,  moans  or  cries  out, 
and  very  frequently  becomes  confused  or  delirious.  Halluci- 
nations of  hearing  and  sight,  painful  in  character,  together 
with  distressing  and  fearful  delusions,  make  their  appearance. 
Occasionally  serious  attacks  of  heart  failure  are  observed;  some- 
times, though  rarely,  there  are  convulsive  seizures.  Not  in- 
frequently the  patient  passes  into  a  collapse,  and,  if  the  case  be 
one  of  years'  standing,  with  probable  changes  in  the  heart 
muscle  and  nerve-centers,  there  is  serious  danger  of  death.  A 
prompt  recourse  to  morphia  will  usually  bring  about  an  abate- 
ment, and,  in  many  cases,  a  disappearance  of  the  alarming 
physical  signs.  The  mental  symptoms,  however,  if  once  estab- 
lis'hed,  tend  to  persist. 

The  mental  symptoms  resulting  from  morphia  withdrawal 
assume  the  form  most  frequently  of  a  very  active  confusion. 
The  intensity  of  the  symptoms  usually  falls  below  that  of  a 
delirium.  Occasionally,  however,  the  onset  is  that  of  a  de- 
lirium which  soon  passes  into  an  active  confusion.  During 
the  most  disturbed  period  hallucinations  of  vision  may  be 
prominent,  but  later  those  of  hearing  predominate. 

The  mental  symptoms  sometimes  arise  when  the  morphia 


232  MENTAL    DISEASES 

withdrawal  has  not  been  complete  and  abrupt,  but  has,  not- 
withstanding, been  too  rapid.  It  is  exceedingly  probable  that 
the  long-continued  ingestion  of  the  morphia  gradually  results 
in  the  production  of  an  antitoxin,  so  that  little  by  little  the 
patient  becomes  more  and  more  tolerant  of  the  drug.  Indeed, 
this  tolerance,  or  relative  immunity,  which  at  times  is  ex- 
traordinary, can  be  explained  on  no  other  ground.  Hirschlaff 
has  demonstrated  the  presence  of  such  an  antitoxic  principle 
experimentally  in  animals.  It  would  seem  that  the  symptoms 
arising  during  the  withdrawal  of  the  drug  are  largely  due  to  the 
unantagonized  action  of  the  accumulated  antitoxin;  the  vomit- 
ing, the  diarrhea,  the  sweating  can  only  be  regarded  as  efforts 
on  the  part  of  nature  at  elimination.  Similarly,  it  is  extremely 
probable  that  the  nerv'ous  disturbances,  the  deUrium  itself, 
are  the  result  of  the  now  unopposed  action  of  this  antibody 
upon  the  nerve-centers.  It  follows,  as  a  matter  of  necessity, 
that  with  the  withdrawal  of  the  morphia  a  definite  group  of 
symptoms  must  make  its  appearance,  and  in  exact  proportion 
and  intensity  to  the  withdrawal  of  the  morphia.  It  stands 
to  reason,  therefore,  that  if  none  of  these  symptoms  is  present, 
and  if  the  patient  continues  comfortable  and  in  good  spirits, 
sleeps  well,  and  is  contented  with  his  surroundings,  he  is  ob- 
taining the  drug  surreptitiously.  It  should  be  remembered 
that  even  under  very  gradual  withdrawal  some  of  the  symp- 
toms mentioned  above  make  their  appearance,  and  may, 
indeed,  become  so  marked  as  to  necessitate  for  a  time  a  return 
to  a  larger  quantity  of  the  drug.  No  picture  is  more  alarming 
than  that  often  presented  by  morphia  patients  in  the  stage 
of  withdrawal,  especially  if  the  depression  produced  by  the 
vomiting  and  diarrhea  be  accompanied  by  mental  confusion 
and  dehrium.  Unfortunately  the  mental  sjTnptoms,  in  spite 
of  all  that  may  be  done,  often  persist  for  a  long  time,  not  only 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     233 

for  days  but   for  many  weeks.     Eventually,   however,   they 
fade  and  disappear. 

In  siumnmg  up  the  mental  phenomena  resultmg  from  chronic 
morphia  poisoning,  we  may  say,  first,  that  the  latter  leads  to  a 
mental  enfeeblement  somewhat  resembling  alcoholic  dementia, 
and  second,  that  its  withdrawal,  probably  through  the  action 
of  an  antitoxin,  may  be  followed  by  delirium  or  confusion,  these 
symptom-groups  again  suggesting  those  occurring  in  the 
course  of  alcoholism. 

COCAINISM 

Cocainism  is  now  and  then  an  indirect  outgrowth  of  nasal 
surgery.  The  patient  learns  that  the  physician  executes 
certain  procedures,  performs  various  operations  upon  the  nose 
after  its  application.  The  application  not  only  renders  the 
area  to  which  the  drug  is  applied  insensitive  but  is  also  followed 
by  a  pleasurable  sense  of  exhilaration.  The  patient  may  suc- 
ceed in  securing  some  of  the  solution  himself,  and  may  begin 
his  abuse  of  the  drug  by  appljdng  it  with  pledgets  of  cotton 
to  the  nose.  Soon,  however,  he  prefers  to  swallow  some  of  the 
solution,  and  a  httle  later  tries  to  procure  the  alkaloid  in  bulk. 

Another  method  in  w^hich  the  habit  of  using  cocain  is  ac- 
quired is  in  connection  with  the  use  of  morphia.  Morphia 
users  frequently  learn  that  they  can  lessen  the  drowsiness  and 
somnolence  of  the  morphia  by  taking  cocain.  Some  of  them 
try  to  cut  doT\Ti  the  morphia  by  adding  cocain,  and  end  by 
acquiring  the  cocain  habit  as  well. 

A  knowledge  of  the  pleasurable  effects  of  cocain  is  widely 
diffused  among  the  lower  classses,  and,  strange  as  it  may  seem, 
especially  in  the  tenderloin  and  slums.  Here  it  is  not  infre- 
quent to  find  it  used,  and  generally  by  persons  who  also  use 
other  intoxicants. 


234  MENTAL    DISEASES 

The  symptoms  of  a  full  dose  of  cocain  consist  especially  in  a 
marked  general  excitement,  in  a  sense  of  exhilaration  and  in- 
toxication. The  patient  is  restless  and  agitated.  He  cannot 
keep  still,  he  is  always  changing  his  position,  getting  up,  sitting 
down,  going  from  one  chair  to  another,  leaving  the  room  and 
coming  back;  often,  too,  he  talks  incessantly;  frequently  he 
complains  of  tingling  in  the  extremities  or  of  ringing  in  the 
ears.  Usually  there  is  pallor  of  the  face,  a  small  rapid  pulse, 
dilatation  of  the  pupils,  sweating,  coldness  of  the  hands  and 
feet,  and  occasional  nausea. 

After  each  successive  dose  the  patient  feels  stimulated;  he 
experiences  an  imperative  need  for  activity,  a  pleasurable 
sense  of  well-being.  Sooner  or  later,  however,  this  gives  way 
to  depression  with  restlessness.  As  in  the  case  of  the  other 
poisons,  he  gradually  becomes  unable  to  do  his  work ;  his  will- 
power and  his  memory  become  impaired.  He  is  weak  and 
irritable,  easily  angered,  unreliable  and  forgetful.  Like  the 
morphinist,  he  wall  lie,  steal,  adopt  any  expedient,  go  to  any 
extreme  to  obtain  the  drug.  More  alert  than  the  morphinist, 
he  is  often  successful,  and  conceals  both  drug  and  syringe  in  the 
most  unexpected  places.  In  cases  in  which  the  habit  has  been 
well  estabhshed,  there  is,  as  in  the  case  of  chronic  alcohohsm 
and  morphinism,  a  more  or  less  marked  impairment  of  energy 
and  will  power,  a  lack  of  purpose  and  concentration,  and  an 
indifference  to  obligations  and  responsibilities.  The  patient's 
general  efficiency  becomes  greatly  reduced  and  finally  lost. 

When  the  drug  has  been  taken  in  large  quantities  and  for  a 
long  time,  more  pronounced  mental  symptoms  may,  as  in  other 
toxic  states,  make  their  appearance.  Just  as  in  the  case  of 
alcohol  and  morphia,  a  more  or  less  persistent  state  of  confusion 
— a  confusional  insanity — may  become  estabhshed.  Under 
these  circumstances,  the  patient  commonly  suffers  from  hal- 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     235 

lucinations,  more  particularly  from  hallucinations  referred 
to  the  surface  of  the  skin,  especially  of  the  extremities.  He 
complains  of  itching,  crawling,  sticking,  and  biting  sensations. 
Sometimes  he  beheves  that  his  body,  his  room,  his  bed  are 
infested  by  fleas  or  some  other  insect.  He  is  continually  wiping, 
brushing,  or  picking  them  off  his  person.  Indeed,  so  common 
is  this  sjTuptom  that  it  is  sometimes  spoken  of  as  ''having 
the  cocain  bug."  Hallucination  of  sight,  of  hearing,  of  taste 
and  smell  may  also  be  present  in  greater  or  less  degree,  but 
the  tactile  hallucinations  are  the  most  prominent  and  striking. 
However,  as  in  alcoholism,  the  patient  may  see  curious  ani- 
mals, shapes  and  phantasms  which  agitate  and  move  before 
him.  The  hallucinations  of  hearing  may  consist  of  whistlings, 
ringings,  inarticulate  cries,  or  words.  Associated  with  his 
hallucinations,  the  patient  may  entertain  painful  and  de- 
pressive delusions.  Like  the  alcoholic,  he  may  evolve  the  de- 
lusion of  marital  infidehty,  but,  unhke  the  alcoholic,  he  is 
not  actively  disturbed  by  it.  His  sleep  is  much  broken. 
Each  dose  of  cocain  prevents  his  sleeping;  it  is  only  after 
access  to  the  drug  has  been  cut  off  that  the  patient  sleeps,  and 
then  he  may  sleep  excessively. 

The  general  nutrition  is  poor.  The  patient  looks  aged  and 
sallow.  His  face  is  expressionless  and  his  movements  betray 
his  bodily  weakness.  His  reflexes  are  usually  somewhat  exag- 
gerated. There  is  tremor  of  the  tongue,  and,  as  already  stated, 
dilatation  of  the  pupils.  Exertion  readily  increases  the  tachy- 
cardia or  brings  on  a  frank  attack  of  palpitation  with  dyspnea 
and  faintness.  Like  the  alcoholic,  he  is  sexually  indifferent 
and  impaired. 

Long-continued  poisoning  by  cocain  results  in  a  more  or 
less  grave  depression  of  nutrition.  The  mental  weakness  may 
become  more  and  more  pronounced,  until  a  condition  analogous 


236  MENTAL    DISEASES 

to  and  resembling  alcoholic  dementia  is  established.  One  such 
case,  which  the  writer  saw  a  number  of  times  in  consultation, 
passed  first  through  a  typical  confusion,  gradually  became 
more  and  more  mindless,  and  finally  died  of  exhaustion.  Cases 
of  such  severity  are,  however,  the  exception.  Quite  commonly 
it  is  found  that  the  withdrawal  of  the  cocain  is  followed  by  a 
more  or  less  rapid  amelioration  and  recovery.  Usually  the 
cocain  can  be  withdrawn  at  once  and  without  any  risk;  there 
is  here  much  less  danger  of  inducing  delirium  and  confusion  than 
in  the  case  of  morphia.  If  confinned  mental  sjnnptoms  are 
present,  however,  these  may  persist  for  a  variable  period  after 
the  drug  has  been  discontinued. 

Not  infrequently  we  meet  with  patients  who  are  alike  the 
victims  of  the  alcoholic,  the  morphia,  and  the  cocain  habits. 
Such  persons  usually  begin  by  abusing  alcohol;  then  attempt 
to  lessen  the  amount  of  alcohol  required  or  to  combat  the  in- 
somnia of  alcoholism  by  taking  morphia;  finally,  they  resort 
to  cocain  to  combat  or  to  aid  in  concealing  the  effects  of  the 
morphia.  Thus  they  become  victims  of  the  triple  habit.  In 
such  cases  the  symptoms  of  the  three  poisons  are  commingled 
in  varying  degree.  As  the  patient's  statements  are  unreliable, 
the  truth  can  only  be  elicited  by  isolating  him,  preventing 
access  to  the  poisons,  and  observing  the  symptoms. 

INTOXICATIONS  BY  CHLORAL  AND  OTHER  DRUGS 
Chloral  has  been  so  largely  displaced  by  the  newer  hypnotics 
that  chloralism  is  now  a  very  infrequent  condition.  Suffice  it 
to  say  that,  like  morphinism,  it  frequently  owes  its  inception 
to  a  prescription  by  a  physician,  the  patient  renewing  the  pre- 
scription without  the  physician's  knowledge  or  consent.  Little 
by  little  the  patient  becomes  accustomed  to  the  drug,  and  soon 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     237 

cannot  sleep  without  it.  It  is  a  poison  which  is  depressing  to 
the  heart  and  vasomotor  apparatus.  Dyspnea,  vertigo,  and 
general  sense  of  weakness  are  among  the  symptoms  likely  to  be 
present.  In  well-established  cases  there  are  marked  nervous- 
ness, marked  insomnia,  and  a  certain  degree  of  mental  weak- 
ness, as  manifested  by  loss  of  will-power  and  failure  of 
memory. 

In  cases  in  which  the  poisoning  is  more  pronounced,  attacks 
of  delirium  may  supervene  which  bear  a  marked  resemblance 
to  delirium  tremens;  or  the  patient  may  be  mildly  confused, 
and  there  may  be  both  visceral  and  auditory  hallucinations. 
The  confusion  is,  as  a  rule,  not  active,  is  attended  by  depres- 
sion, and  may  superficially  suggest  melancholia. 

Other  hypnotics  may  yield  similar  symptom-groups  to  those 
above  described;  each  is,  of  course,  featured  by  its  own  special 
symptoms.  The  application  of  general  principles  readily  leads 
to  a  correct  interpretation.  Among  the  drugs  to  be  borne  in 
mind  are  trional,  sulphonal,  veronal,  medinal,  and  paraldehyd. 
It  cannot  be  claimed  that  the  use  of  these  drugs  is  common. 
They  are  sometimes  taken  by  alcoholics  to  combat  insomnia, 
and  may  thus  complicate  the  picture.  Paraldehyd  is  occa- 
sionally taken  directly  with  the  whisky. 

3.    DISORDERS    OF    METABOLISM 

Of  the  disorders  of  metabolism,  three  only  will  merit  con- 
sideration here;  namely,  diabetes,  gout,  and  obesity.  Other 
general  disturbances  of  nutrition  are  considered  in  connection 
with  diseases  of  the  ductless  glands  and  of  other  viscera.  Some 
of  the  more  recondite  problems  have  already  been  discussed 
in  connection  with  dementia  prsecox  (see  p.  131)  and  with 
manic-depressive  insanity  (see  p.  106). 


238  MENTAL    DISEASES 

DIABETES 

Diabetes  is  a  symptom  group  in  which,  as  is  well  known,  the 
pancreas,  the  ductless  glands,  and  the  nervous  system  play  a 
varied  role.  At  first  sight  it  may  seem  unscientific  to  attempt 
to  correlate  mental  phenomena  with  an  affection,  the  nature 
of  which  is  itself  as  yet  imperfectly  understood;  however,  in 
a  certain  number  of  diabetics,  nervous  and  mental  s3anptoms 
are  definitely  present.  The  clinical  facts  are  well  known,  and 
may  be  here  briefly  summarized. 

The  patient  suffering  from  diabetes  may  become  depressed, 
quiet,  and  easily  disturbed.  His  capacity  for  intellectual  labor 
diminishes;  he  becomes  apathetic  and  indifferent,  and  lacks  his 
former  "^-ill-power.  A  mental  enfeeblement  simulating  a  de- 
mentia may  become  established.  Speech  may  be  imperfectly 
enunciated  and  the  gait  and  movements  uncertain.  A  mild 
confusion,  with  depressive  and  painful  ideas,  makes  its  appear- 
ance. Often  the  mental  condition  resembles  melancholia  and 
ideas  of  suicide  are  not  infrequent.  Occasional  episodes  of 
excitement,  with  accentuation  of  symptoms,  are  present,  but 
a  delirium  is  rare.  At  other  times,  and  more  frequently,  the 
patient  suffers  from  spells  of  drowsiness  or  frank  attacks  of 
somnolence.  These  may  recur  or  may  gradually  or  at  once 
pass  into  stupor,  the  so-called  diabetic  coma. 

Diabetic  Coma. — Diabetic  stupor  or  coma  may  appear  at 
any  time  in  the  course  of  a  diabetes,  in  the  beginning,  in  the 
fully-developed  period,  or  in  the  final  stage  of  the  affection. 
It  is  sometimes  of  sudden,  sometimes  of  gradual,  evolution.  In 
the  last-mentioned  instance,  certain  prodromal  sjTnptoms  may 
be  present.  Thus,  there  may  be  depression  or  unusual  excite- 
ment and  restlessness,  physical  weakness,  mental  exhaustion, 
headache,  sleeplessness,  and  dizziness.     The  quantity  of  urine 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     239 

for  the  twenty-four  hours  may,  during  this  period,  be  decidedly 
diminished. 

The  attack  begins  quite  frequently  vaih  nausea  and  vomiting 
and  with  a  copious  and  watery  diarrhea.  Sometimes  there  are 
abdominal  pains  accompanied  by  distension  of  the  abdomen. 
Usually  there  is  a  sweetish  odor  to  the  breath.  The  respira- 
tion is  embarrassed;, the  inspiration  is  long,  difl&cult,  and  deep, 
while  the  expiration  is  sudden  and  short.  The  pulse  is  regular, 
though  usually  small  and  rapid.  Auscultation  reveals  no 
changes  in  the  heart  or  lungs.  The  movements  of  respiration, 
normal  in  number  at  first,  become  diminished  as  the  coma  is 
estabhshed. 

The  onset  of  the  coma  may  be  preceded  by  a  short  period 
of  excitement,  agitation,  cries,  incoherence,  purposeless  move- 
ments and  gestures.  Soon  the  patient  becomes  quiet  and 
torpid;  soon  he  can  no  longer  be  roused  and  passes  into  a  pro- 
found coma.  The  patient  hes  extended  and  inert;  his  face  is 
pale,  his  pupils  dilated,  his  limbs  relaxed.  The  temperature 
becomes  subnormal  and  death  ensues  in  from  a  few  hours  to  three 
or  four  days.  If  the  attack  is  not  severe  the  patient  may  re- 
cover, only,  however,  to  suffer  from  a  recurrence,  perhaps  re- 
peated,  and  finally  fatal. 

For  the  condition  of  the  urine,  the  reader  is  referred  to  text- 
books upon  internal  medicine.  Sufiice  it  to  say  here,  that 
the  examination  of  the  urine  reveals  the  presence  of  acetone 
bodies  in  decided  amounts,  especially  of  B-oxybutyric  acid, 
to  which  the  coma  is  due;  and  diabetic  coma  is  to  be  distin- 
guished from  attacks  of  uremia,  from  alcohohc  intoxication, 
from  apoplexies,  by  the  examinaton  of  the  urine.  We  should 
remember,  in  this  connection,  that  in  some  diabetics,  though 
infrequently,  the  attack  is  complicated  by  uremia.  Pending 
the  examination  of  the  urine,  the  sweetish  odor  of  the  breath 


240  MENTAL    DISEASES 

and  the  character  of  the  breathing  may  suggest  the  nature  of 
the  attack. 

GOUT 

Mental  symptoms  the  result  of  gout  are  very  rare.  However, 
they  are  now  and  then  met  with,  and  appear  to  bear  a  relation 
to  the  sudden  recession  of  local  gouty  manifestations.  The 
mental  disturbances  of  gout  manifest  themselves  most  fre- 
quently in  an  active  delirium,  usually  of  short  duration  and  of 
irregular  recurrence.  Less  often  the  attack  consists  of  an 
active  and  prolonged  confusion.  One  such  patient  under  the 
writer's  care  presented  vivid  hallucinations  of  both  sight  and 
hearing.  The  visual  hallucinations  consisted  apparently  of 
dark  objects  and  images;  negroes  were  frequent;  while  the 
auditory  hallucinations  consisted  of  threatening  voices,  cries, 
and  other  distressing  sounds.  The  delusions  were  corre- 
spondingly painful.  The  attack  lasted,  with  varying  periods 
of  improvement,  for  about  five  months. 

ADIPOSIS 
Adiposis,  ordinarily,  does  not  present  mental  symptoms  of 
consequence.  However,  apathy,  inertia,  mental  weakness,  and 
somnolence  may  make  their  appearance,  especially  in  cases 
in  which  the  adiposity  is  related  to  disease  of  the  internal  secre- 
tions. Delirious  and  confused  states  are  infrequent.  Notwith- 
standing, they  are  now  and  then  met  with  in  adiposis  dolorosa. 
In  this  affection  a  cerebral  asthenia  or  ready  cerebral  exhaustion 
is  rarely  absent.  Many  patients  present,  in  addition,  great 
irritability;  this  is  at  times  so  great  as  to  be  att-ended  by  a 
change  in  character  and  disposition.  The  least  opposition 
may  enrage  the  patient,  and  not  infrequently  she  will  quarrel 
Avith  her  neighbors  in  the  wards  to  such  an  extent  that  isolation 
becomes  imperative.     Sometimes  she  thinks  that  the  other 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     241 

patients  and  the  nurses  are  against  her.  The  sleep  is  usually 
broken  and  disturbed  by  distressing  dreams  and  nightmares. 
One  of  Eshner's  patients  was  disturbed  mentally  to  such  an 
extent  as  to  necessitate  her  commitment  to  an  asylum.  Hale 
White's  case  had  two  attacks  of  mental  disturbance.  Giudice- 
andrea  has  noted  delusions  of  persecution  and  a  true  dementia. 

4.    THE    VISCERAL    DISEASES 

Visceral  diseases  profoundly  affect  the  organism  as  a  whole. 
At  times,  as  in  Bright's  disease,  toxic  substances  are  no  longer 
eliminated  and  are  retained  in  the  circulation;  at  other  times,  as 
in  malignant  disease,  toxic  substances  foreign  to  the  organism 
are  produced  and  find  an  entrance  into  the  blood.  Uremic 
coma  or  stupor  is  so  common  as  not  to  merit  special  mention, 
but  it  serves  to  illustrate  in  a  forcible  way  the  depressive  action 
of  retained  poisons  upon  the  nervous  system.  There  are, 
however,  states,  much  less  common,  of  delirium  and  confusion, 
occurring  both  in  Bright's  disease  and  other  visceral  affections, 
and  these  demand  a  brief  consideration. 

At  the  outset  we  realize  the  relative  infrequency  of  mental 
disturbances,  for  example,  in  Bright's  disease,  and  the  truth 
is  at  once  apparent  that  some  added,  some  special  factor, 
must  be  present.  This  exists  in  the  pre-existing  neuropathy 
of  the  patient.  Surely,  if  the  ordinary  man,  who  is  ill  for 
months  and  years  with  Bright's  disease,  betrays  no  mental 
symptoms  in  response  to  the  toxemia,  the  man  in  whom  such 
symptoms  do  appear  must  be,  other  things  equal,  unusually 
vulnerable,  and  this  is  the  case. 

As  in  the  case  of  other  poisons  acting  upon  the  nervous 
system,  the  symptoms  produced  are  those  of  delirium,  confusion, 
and  stupor;  and  this  is  true  of  all  of  the  psychoses  of  visceral 

16 


242  MENTAL    DISEASES 

origin.  The  relatively  infrequent  disturbances  met  with  in 
Bright's  disease  will  serve  as  an  example. 

Patients  suffering  from  Bright's  disease  may  manifest  de- 
lirium. There  are  headache,  hallucinations,  and  illusions,  both 
auditory  and  visual.  The  patient  talks  confusedly,  is  actively 
disturbed,  and  may  be  much  agitated.  The  attack  may  pass 
away  or  may  be  interrupted  by  convulsions  or  may  deepen  and 
terminate  in  coma.  The  intensity  of  the  symptoms  and  the 
prognosis  of  the  attack  stand  of  course  in  close  relation  to  the 
Bright's  disease. 

In  other  cases  the  disturbance  assumes  the  form  of  a  confu- 
sion with  depression.  Hallucinations  are  present  as  before. 
The  patient  may  be  afraid,  may  entertain  persecutory  notions, 
or  his  ideas  may  be  vague,  mystic,  and  difficult  to  follow.  Now 
and  then  the  symptoms  resemble  melancholia.  The  course  of 
the  attack  may  be  interrupted  by  periods  of  exacerbation,  in 
which  the  patient  may  be  frankly  delirious;  at  times  these  epi- 
sodes are  attended  by  great  excitement.  Again,  at  any  time  in 
the  course  of  the  attack,  convulsions  and  coma  may  supervene. 

Symptoms  of  delirium  and  confusion,  mild  in  character,  at- 
tended by  depression,  painful  in  type  and  superficially  suggest- 
ing melanchoUa  may  make  their  appearance  in  the  course  of 
almost  any  of  the  visceral  diseases,  more  especially,  however,  of 
the  gastro-intestinal  tract  and  of  the  liver.  Here  we  have  again 
to  deal  with  the  phenomena  of  auto-intoxication,  frequently  su- 
perimposed on  a  neuropathic  make-up.  In  brief,  the  inference 
should  be  drawn  that  the  existence  of  a  dehrium  or  of  a  confusion 
which  bears  no  clear  relation  to  an  infection  or  intoxication 
should  always  excite  the  suspicion  of  visceral  or  other  somatic 
disease.  Quite  commonly  the  disturbance  is  not  attended  by 
much,  if  any,  excitement.  This  is  the  case,  for  instance,  in 
maUgnant  affections;  e.  g.,  cancer  of  the  stomach. 


MENTAL    DISEASE    RELATED    TO    SOMATIC   AFFECTIONS     243 

The  mental  disturbance  in  malignant  disease  is  never  active; 
there  is  never  a  delirium.  The  patient  is  depressed,  irritable, 
has  vague  hallucinations,  and  often  entertains  persecutory 
ideas.  The  depression  is  marked,  and,  when  coupled  with  a 
realization  of  the  serious  nature  of  the  physical  disease  from 
which  the  patient  suffers,  may  lead  to  suicide.  When  the  con- 
fusion is  profound,  the  patient  with  gastric  cancer  may  talk  of 
snakes  or  other  living  things  in  his  stomach;  the  woman  with 
cancer  of  the  uterus  may  talk  of  being  pregnant.  Under  all 
circumstances,  it  should  be  repeated,  the  previously  existing 
neuropathy  should  never  be  lost  sight  of. 

DISEASES    OF    THE    DUCTLESS    GLANDS 

Diseases  of  the  ductless  glands  merit  a  special  consideration. 
Particularly  is  this  true  of  the  thyroid  gland.  Here  we  can 
distinguish  the  mental  symptoms  of  hyperthyroidism,  hypo- 
thyroidism, and,  less  clearly,  of  dysthyroidism. 

The  mental  symptoms  of  hyperthyroidism  are  met  with  now 
and  then  in  exophthalmic  goiter,  occasionally  in  the  rare  in- 
stances of  surgical  injury  of  the  thyroid  gland  in  which  the  gland 
or  its  connective  tissue  envelope  are  torn,  and  finally  in  opera- 
tions in  which  the  manipulation  of  the  gland  has  forced  an 
undue  amount  of  secretion  into  the  circulation.  It  may  also 
occur  in  thyroid  administration,  when  the  patient  is  unduly 
susceptible  or  when  the  dose  has  been  large. 

The  symptoms  are  those  of  a  more  or  less  active  delirium. 
The  patient  suffers  from  hallucinations  of  sight  and  hearing 
and  is  actively  disturbed.  He  sees  faces,  hears  voices,  suffers 
from  distressing  delusions,  is  very  restless,  and  often  noisy. 
At  times  the  delirium  attains  a  very  high  degree  of  intensity. 
It  may  also  be  attended  by  a  decided  rise  of  temperature. 

In  exophthalmic  goiter,  delirium  is  only  occasionally  observed. 


244  MENTAL    DISEASES 

It  is  rather  the  symptom  group  of  a  relatively  mild  but  chronic 
intoxication  which  presents  itself.  Thus,  the  patient  is  com- 
monly nervous,  irritable,  and  excitable.  Sometimes  his  con- 
dition suggests  a  mild  manic  state;  at  other  times  he  is  for- 
getful, indifferent,  or  listless,  or  perhaps  a  little  depressed  and 
suspicious.  The  depression  may  be  quite  marked  and  attended 
by  a  mild  confusion,  and  this  confusion  may  be  interspersed  by 
episodes  of  excitement  or  delirium.  Sometimes,  however,  a 
frank  delirium  makes  its  appearance  quite  suddenly  and  with- 
out premonitory  signs  of  moment.  It  happens  every  now 
and  then  that  the  symptoms  of  the  exophthalmic  goiter  are 
moderate  or  but  slightly  and  imperfectly  marked  and  yet  the 
mental  symptoms  are  pronounced.  Sleep,  as  might  be  pre- 
dicted, is  usually  much  disturbed  and  abridged,  though  cases 
are  not  wanting  in  which  somnolence  is  noted.  It  is  probable 
that  the  latter  are  cases  of  exophthalmic  goiter,  in  which,  for 
some  reason  or  other,  there  is  a  momentary  depression  of  func- 
tion or  exhaustion  of  the  thyroid  rather  than  a  hyperthyroidism. 

Thyroid  delirium  offers,  other  things  equal,  a  favorable 
prognosis.  Of  course  the  thyroid  intoxication  may  be  in  indi- 
vidual cases  so  massive  as  to  lead  to  death.  Such  may  be  the 
outcome  in  traumatic  cases  or  cases  in  which  toxic  doses  of  thy- 
roid substance  have  been  taken.  Again,  there  are  cases  of  ex- 
ophthalmic goiter  in  which  delirium  supervenes,  and  in  which  a 
more  or  less  chronic  intoxication  follows;  that  is,  cases  in  which 
marked  mental  symptoms  persist  for  an  indefinite  period .  Such 
cases  are  every  now  and  then  committed  to  the  asjdums.  Very 
curiously,  too,  we  have  here  often  to  deal  with  cases  in  which,  as 
already  pointed  out,  the  symptoms  of  the  exophthalmic  goiter, 
though  present,  are  not  pronounced.  Doubtless  a  predisposi- 
tion, a  pre-existing  neuropathy,  plays  here  a  role. 

The  mental  symptoms  of  hypothyroidation  may  ensue  when 


MENTAL    DISEASE   RELATED    TO    SOMATIC    AFFECTIONS     245 

the  gland  undergoes  destruction  or  atrophy  through  some  de- 
generative or  diseased  process;  it  may  also  follow  a  too  radical 
surgical  removal  of  the  gland.  The  picture  that  supervenes 
is  that  of  the  well-known  symptom  group  of  myxedema.  Here, 
in  addition  to  the  infiltration  of  the  skin,  the  swollen  features, 
the  spade-like  hands,  the  sausage-shaped  fingers,  the  dryness 
of  the  skin,  slowing  of  the  pulse  and  subnormal  temperature, 
mental  phenomena  are  present  in  greater  or  less  degree.  There 
is  a  slowing  of  thought  and  of  mental  processes  generally. 
There  is  difficulty  of  comprehension;  the  patient  cannot  follow 
a  prolonged  conversation;  the  memory  is  impaired,  and,  in  addi- 
tion, there  is  readiness  of  fatigue.  The  patients  are  slow  in 
their  movements,  require  an  excessively  long  time  to  perform 
the  simplest  acts.  As  in  the  neurasthenic-neuropathic,  the 
psychasthenic  cases,  the  patient  sometimes  requires  hours  to 
dress,  to  bathe,  or  to  attend  to  such  elementary  functions  as  a 
movement  of  the  bowels. 

Mentally  the  patients  are  heavy,  dull,  apathetic.  At  the 
same  time,  especially  if  pressure  is  put  upon  them  in  the  attempt 
to  make  them  hurry,  they  maj^  become  greatly  excited  and 
nervous.  Usually  they  sleep  a  great  deal;  sometimes  there  is  a 
pronounced  somnolence.  In  given  cases,  drowsiness  or  sleepiness 
comes  on  in  attacks;  or  the  patient  may  suddenly  fall  asleep 
for  varying  periods  of  time,  a  true  narcolepsy  being  present. 
On  the  other  hand,  though  less  frequently,  the  sleep  may  be 
both  diminished  and  disturbed.  Now  and  then  it  is  observed 
that  the  patient  is  mildly  confused;  hallucinations  may  be  pres- 
ent, accompanied,  it  may  be,  by  distressing  delusions;  sometimes 
the  patient  feels  that  he  is  being  ill-treated,  abused,  or,  it  may 
be,  persecuted.  Now  and  then  the  patient  complains  of  head- 
ache, sense  of  pressure,  faintness,  or  dizziness;  and  rarely  convul- 
sive attacks  resembling  epilepsy  make  their  appearance.    If  the 


246  MENTAL    DISEASES 

affection  remain  unrecognized,  and  proper  treatment  be  not  in- 
stituted, the  mental  condition  finally  terminates  in  a  dementia. 

At  times,  and  this  is  most  important,  the  mental  symptoms 
of  myxedema  are  pronounced  while  the  physical  signs  are  not 
decided  or  so  slightly  marked  as  perhaps  to  be  overlooked. 
In  the  writer's  experience  cases  of  complete,  of  fully  developed, 
myxedema  presenting  the  typical  classical  symptoms  are  rare; 
on  the  other  hand,  cases  of  incomplete  myxedema  are  relatively 
frequent.  In  such  cases  the  infiltration  of  the  skin,  the  dry- 
ness of  the  hair,  the  slowing  of  the  pulse  may  be  relatively 
moderate  or  even  slight  and  yet  the  mental  symptoms  pro- 
nounced. The  importance  of  the  recognition  of  early  or  in- 
complete cases  of  myxedema  cannot  be  sufficiently  emphasized. 

Finally,  there  are  disturbances  of  the  th>Toid  gland  in  which 
the  symptoms  present  do  not  enable  us  to  classify  a  given  case 
either  as  hyperthyroidism  or  hypothyroidism,  and  in  which, 
notwithstanding,  the  functions  of  the  gland  are  affected.  Possibly 
in  such  cases  several  ductless  glands  are  synchronously  involved. 
That  a  varied  symptom-group  of  excitement  and  depression, 
of  confusion  or  delirium,  should  occasionally  be  present  under 
such  circumstances  is  not  surprising.  It  is  also  a  significant  fact 
that  in  mental  cases,  as  a  whole,  evidences  of  thyroid  anomahes 
of  one  kind  or  another  are  relatively  frequent.  The  examination 
at  random  of  large  numbers  of  miscellaneous  cases,  as,  for  in- 
stance, in  an  asylum,  reveals  the  truth  of  this  statement. 

Diseases  of  the  ductless  glands  other  than  the  thyroid  are 
not  attended  with  equally  well-marked  symptom-groups  of 
mental  phenomena.  At  the  same  time,  special  disease  of  the 
pituitary — e.  g.,  excess  of  function,  as  in  acromegaly,  or  di- 
minution of  function,  as  in  adiposis — may  be  associated  with 
unmistakable  psychic  symptoms.  Thus,  in  acromegaly  there 
may  be  somnolence  or  there  may  be  apathy  and  dementia,  the 


MENTAL    DISEASE   RELATED    TO    SOMATIC    AFFECTIONS     247 

latter  sometimes  very  slight  and  sometimes  very  marked. 
Similar  symptoms  may  be  met  with  in  pituitary  deficiency; 
e.  g.,  somnolence,  mental  impairment  or  feebleness.  In  adrenal 
disease  there  may  be  depression.  In  disease  of  the  pineal  gland 
there  may  be,  in  hj'perpinealism,  sexual  and  intellectual  pre- 
.  eocity,  and,  probably,  in  hypopinealism,  a  failure  of  the  cor- 
responding functions.  Perhaps  it  plays  a  role  in  paranoia 
originaria  (see  p.  332).  Finally,  we  should  bear  in  mind  that  the 
ductless  glands  form  a  closely  related  and  interdependent  chain, 
and  disturbance  of  one  of  them  sometimes  ehcits  phenomena 
in  the  others.  A  discussion  of  this  interesting  subject  would 
unfortunately  take  us  too  far  afield.  The  reader  is,  however, 
referred  to  the  role  of  the  hormone  of  the  sex  glands  and  of  the 
other  internal  secretions  in  dementia  preecox  (see  p.  131),  and 
also  to  the  possible  role  of  the  latter  in  manic-depressive  in- 
sanity (see  p.  106). 

5.    DISEASES    OF    THE    NERVOUS    SYSTEM 

The  diseases  of  the  nervous  system  which  especiallj^  demand 
here  a  consideration  are,  first,  the  functional  disorders,  epilepsy, 
hysteria,  chorea,  and  paralysis  agitans,  and,  second,  the 
organic  diseases,  paresis,  cerebral  syphiHs,  multiple  cerebro- 
spinal sclerosis,  arteriosclerosis,  hemorrhage,  emboHsm,  throm- 
bcfsis,  brain  tumor,  brain  abscess,  tabes,  and  trauma. 

A,     FUNCTIONAL    NERVOUS    DISEASES 

EPILEPSY 
As  is  well  known,  many  and  widely  differing  factors  enter 
into  the  etiology-  of  epilepsy.  Among  these  are,  first,  heredity; 
secondly,  neuropathy,  alcohohsm,  syphihs  and  possibly  other 
infections  in  the  ancestry;  thirdly,,  causes  acting  direct^  upon 
the  individual  himself,  such  as  intoxications,  infections,  trauma 
and  gross  organic  disease  of  the  brain;  perhaps  also  disturbances 


248  MENTAL    DISEASES 

of  the  internal  secretions.  Under  the  caption  of  epilepsy  we  are 
in  the  habit  of  including  many  symptom  groups  which  differ 
widely  as  to  their  origin  and  pathology.  Perhaps  this  is  not 
surprising  when  we  reflect  on  the  physiology  of  the  brain. 
It  would  appear  that  the  motor  area  of  the  cortex  responds  by 
convulsive  attacks  to  both  chemical  and  physical  irritants, 
and,  that  there  should  be  a  multiplicity  of  causes,  any  one  or 
number  of  which  may  bring  about  an  epileptic  symptom  group, 
is  perhaps  just  what  we  should  have  been  led  to  expect.  While 
a  classification  of  the  epilepsies  is  a  matter  of  extreme  difficulty, 
we  can  safely  separate  out  from  the  great  mass  of  cases  a  group 
in  which  there  are  present,  sometimes  in  slight  and  sometimes 
in  marked  degree,  the  evidences  of  morphological  arrest  and 
deviation.  Among  these  are  anomalies  in  the  size  and  shape  of 
the  skull,  a  high  and  narrow  palate,  anomalies  of  dentition, 
anomalies  of  the  ears,  of  the  digits,  and  of  the  general  develop- 
ment. Sometimes  the  arrest  is  characterized  not  so  much  by 
physical  signs  as  by  a  mental  development  distinctly  sub- 
normal. It  is  just  in  this  group  of  cases  that  we  find  significant 
factors  in  the  ancestry  such  as  epilepsy  or  other  neuropathy, 
syphilis,  and  alcohoHsm.  It  is  in  this  group  that  we  have  to  deal 
with  individuals  whose  development  has  taken  place  in  an 
aberrant  and  damaged  germ  plasm  and  in  whom  the  epilepsy 
is  expressive  of  an  endogenous  autotoxic  disease.  It  is  to  this 
group  that  the  term  morphologic  or  essential  epilepsy  seems 
clearly  applicable. 

The  epilepsies  of  other  origin  may,  in  given  instances,  be 
accompanied  by  mental  symptoms,  all  more  or  less  related  to 
the  special  cause  of  origin,  but  the  descriptions  which  follow 
relate  only  to  the  epilepsy  of  the  morphologic  or  essential  group. 

The  psychic  manifestations  of  epilepsy  vary  very  greatly. 
Frequently  no  psychic  disturbance,  save  the  loss  of  conscious- 
ness accompanying  the  attack,  is  noted;  at  times  special  psy- 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS      249 

chic  symptoms  are  present  and  precede  the  attack;  at  others 
follow  the  attack,  and  at  others  still  replace  the  attack.  It  is 
noted,  furthermore,  that  mental  deterioration  ensues  in  long- 
standing cases.  Finally,  a  careful  study  of  the  epileptic  in  the 
interparoxysmal  periods  frequently  reveals  special  phenomena 
which  distinguish  him  from  the  normal  individual. 

There  are,  of  course,  epileptics  who,  in  the  intervals  between 
the  seizures,  are  entirely  normal,  and  are  able  to  follow  their 
vocations  fairly  well.  There  are  others,  however,  and  by  far 
the  greater  number,  who  present  both  emotional  irritabihty 
and  mental  impairment.  These  symptoms  may  be  slight,  but 
more  frequently  are  very  evident.  Usually  the  epileptic  has  no 
difficulty  of  comprehension  and  his  faculty  of  orientation  is 
unimpaired,  but  we  soon  realize  that  his  mental  processes  are 
distinctly  slow.  In  keeping  with  this,  he  is  commonly  dull  and 
apathetic  and  at  the  same  time  unduly  irritable.  His  emo- 
tional equilibrium  is  readily  disturbed,  his  inhibition  is  di- 
minished, and  he  may  be  quarrelsome  and  easily  angered; 
indeed,  sudden  outbreaks  of  anger  from  little  or  no  cause  are 
not  infrequently  observed.  Further,  his  mental  activity  is 
distinctly  diminished,  and,  as  in  other  affections  in  which  a 
mild  dementia  is  becoming  established,  the  patient  learns  with 
difficulty  and  Hves  in  a  comparatively  limited  horizon.  His 
thoughts  lose  their  spontaneity,  are  apt  to  pursue  the  beaten 
path;  this  becomes  evident,  both  in  his  replies  to  questions 
and  in  the  account  which  is  elicited  of  his  symptoms. 

As  in  mental  deficiency  due  to  other  causes,  a  more  or  less 
marked  impairment  of  memory  becomes  evident  as  the  affec- 
tion progresses.  It  may  be  slight  at  first  and  may  manifest 
itself  only  by  an  occasional  forgetfulness.  Later  it  may  be- 
come more  marked,  until  finally  the  history  which  the  patient 
gives  of  himself  varies  from  time  to  time  and  later  becomes, 


250  MENTAL    DISEASES 

in  part  at  least,  clearly  unreliable.  Mental  obtusion  is  further 
shown  by  the  patient's  inability  to  realize  the  change  in  his  o^vn 
condition.  Both  the  seizures  and  the  mental  impairment  may 
be  growing  distinctly  worse,  and  yet  the  patient  may  answer 
that  he  is  getting  better.  At  times  he  seems  to  be  afraid  and 
depressed,  and  at  others  suspicious,  and,  occasionally,  he  may 
evolve  persecutory  ideas,  usually  changing  and  transitory; 
rarely  a  distinctly  expansive  attitude  is  noted. 

The  mental  state  of  epileptics,  as  already  indicated,  differs 
greatly  in  different  cases.  There  are  some  in  whom  the  attacks 
exist  for  many  years  and  yet  in  whom  little  if  any  deterioration 
is  noted.  The  patients  may  for  a  long  time  pursue  quiet  and 
well-ordered  lives.  Doubt  may,  however,  properly  be  enter- 
tained as  to  the  accuracy  of  statements  to  the  effect  that  epi- 
lepsy may  not  only  be  unattended  by  deterioration  but  may  even 
exist  in  persons  of  unusual  or  phenomenal  mental  endowment; 
thus,  both  Caesar  and  Napoleon  are  conunonly  spoken  of  as 
epileptics,  and  yet  the  suspicion  that  the  attacks  from  which 
they  suffered  were  really  hysteric  is  not  without  justification. 
It  is  significant,  also,  that  a  certain  degree  of  mental  impair- 
ment becomes  gradually  and  very  slowly  established,  and  the 
patients  then  remain  in  this  impaired  condition  without  further 
change.  There  are  others  still — those,  it  may  be,  in  whom  seiz- 
ures have  recurred  with  great  frequency  and  great  severity — 
in  whom  the  deterioration  is  relatively  rapid  and  progressive, 
and  who  finally  become  markedly  demented.  Profound  de- 
mentia, however,  such  as  is  met  with  in  other  terminal  states, 
is  uncommon. 

More  interesting  and  more  important  than  epileptic  dementia 
are  the  episodic  mental  states.  These  consist  of  periods  some- 
times very  brief,  sometimes  prolonged,  in  which  the  mental 
processes  are  distinctly  modified  or  retarded,  or  in  which  the 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS      251 

patient  is  mildly  or  actively  confused  or  delirious.  They  may 
immediately  precede  a  convulsive  seizure,  in  which  case  they 
constitute  a  psychic  aura.  They  may  precede  the  seizure  by 
several  hours,  or  it  may  be  for  a  day  or  more,  in  which  case 
they  are  spoken  of  as  psychic  prodromata.  Again,  they  may 
follow  a  seizure,  in  which  case  they  may  be  regarded  as  psychic, 
sequelae.  Finally,  the  mental  symptoms  may  constitute  the 
entire  attack  and  thus  replace  altogether  the  convulsive  seizure. 
Such  a  case  is  commonly  spoken  of  as  a  psychic  epilepsy; 
sometimes  as  a  larvated  epilepsy. 

If  the  mental  symptoms  manifest  themselves  as  prodromata 
we  observe,  first,  that  the  pecuharities  ordinarily  noted  in  the 
patient  become  accentuated.  His  irritabihty,  dulness,  heavi- 
ness are  increased.  He  may  become  sullen,  more  apathetic, 
more  quarrelsome.  Sometimes  a  kind  of  psychic  erethism  is 
present,  the  patient  becomes  very  excitable,  not  only  emotion- 
ally but  at  times  also  intellectually.  He  may  in  such  case  be 
restless,  talkative,  and  even,  though  rarely,  expansive.  Sooner 
or  later  the  convulsive  seizure  follows. 

The  psychic  aura  when  present  manifests  itself  very  fre- 
quently as  a  sudden  fear  or  fright.  Not  infrequently,  for 
instance,  a  child  about  to  have  a  convulsion  suddenly  clings 
to  its  mother,  screams,  and  manifests  all  the  outward  signs  of 
an  intense  fright.  Tn  other  cases,  the  patient  may  suddenly 
become  excited,  talk  of  something  terrible  about  to  happen, 
of  ruin  and  destruction;  or  he  may  suddenly  become  stupid, 
unable  to  comprehend  what  is  said  to  him  or  what  is  going  on 
about  him.  At  other  times,  he  becomes  suddenly  agitated, 
passes  through  various  automatic  movements,  goes,  comes, 
runs,  or  performs  various  and  sometimes  bizarre  acts.  Some- 
times* the  excitement  is  very  intense,  and  the  patient  may 
suddenly  become  destructive  and  may  make  violent  attacks 


252  MENTAL    DISEASES 

on  the  persons  and  objects  about  him.  That  terrifying  hal- 
lucinations and  delusions  are  present  in  such  cases  is  very 
probable.  The  various  forms  which  the  psychic  aura  assumes 
are  relatively  short  in  duration;  the  convulsion  appears  and 
all  mental  manifestations  cease. 

Psychic  manifestations  are  less  frequent  after  the  convulsion, 
has  occurred  than  before.  However,  dulness,  apathy,  mental 
confusion  may  be  present  in  more  or  less  marked  degree. 
Sometimes  confusion  persists  for  several  hours,  especially  in 
cases  in  which  the  seizures  are  very  severe  or  occur  in  groups. 

When  the  mental  disturbance  constitutes  the  entire  attack, 
the  case,  as  has  already  been  stated,  is  spoken  of  as  psychic 
or  larvated  epilepsy.  Compared  with  ordinary  epilepsy, 
purely  psychic  epilepsy  must  be  regarded  as  very  infrequent. 
When  it  occurs,  the  symptoms  assmne  the  form  either  of  a  con- 
fusion or  a  delirium.  Dehrium  is,  on  the  whole,  the  most 
frequent.  As  a  rule,  the  attack  is  preceded  by  depression. 
Often  there  is  a  history  of  frightening  dreams.  The  patient 
complains  of  strange  sensations  or  of  a  dazed  feeling.  Sud- 
denly there  is  an  outbreak.  Vivid  hallucinations  of  sight  and 
hearing  make  their  appearance.  The  patient  screams,  cries  out, 
and  evidently  sees  terrifying  objects,  blood,  flames,  hears  terrible 
sounds  and  voices,  and  has  terrifying  delusions.  He  struggles, 
makes  wild  attacks,  frenzied  efforts,  and  maj'  even  kill  while  in 
this  condition.  He  is  entirely  obli\dous  of  his  surroundings 
during  the  seizure,  and  subsequently  has  no  recollection  of  what 
has  occurred.  Occasionally  the  seizure  is  less  pronounced.  The 
hallucinations  and  delusions  are  less  active  and  consciousness 
may  not  be  so  completely  obscured. 

As  a  rule,  the  duration  of  the  attack  is  several  hours,  several 
days,  or  perhaps  as  much  as  two  weeks  or  more.  The  more 
active  the  excitement,  other  things  equal,  the  shorter  the  dura- 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS      253 

tion.  Again,  the  violence  of  the  outburst  may  gradually  give 
way  to  a  less  active  phase,  and  this  is  usually  the  case  when 
the  attack  is  prolonged.  Sometimes  the  subsidence  of  the 
symptoms  and  the  return  to  lucidity  is  rapid  or  even  sudden; 
more  frequently  the  return  is  gradual. 

Instead  of  dehrium,  the  patient  may  suffer  from  confusion. 
This  confusion  may  be  active  or  it  may  be  slight.  Again  the 
attacks  may  be  evanescent  in  their  duration  or  excessively 
prolonged.  In  one  of  the  cases  studied  by  the  writer,  the  con- 
fusion occurred  in  brief  episodes  of  several  minutes,  apparently 
replacing  less  frequently  recurring  convulsive  seizures.  In 
other  cases  the  confusion  may  be  more  pronounced  and  last 
several  hours,  several  weeks.  Occasionally  it  is  terminal  to  a 
delirium.  Finally,  it  may  be  very  deep  or,  on  the  other  hand, 
so  light  that  the  patient  is  merely  somewhat  dazed.  As  in  the 
case  of  epileptic  delirium,  consciousness  is  lost,  and  when  the 
attack  is  over  the  patient  has  no  recollection  of  what  has 
occurred. 

The  confusion  may  in  given  instances  deepen  into  stupor 
or  the  latter  may  make  its  appearance  suddenly.  The  stupor 
may  be  complete;  more  frequently  the  condition  is  that  of  an 
incomplete  stupor,  a  deep  confusion,  in  which  the  patient  may 
manifest  purposeless  and  automatic  movements  and  gestures, 
or  may  betray  in  other  ways  evidences  of  a  confused  and  hallu- 
cinatory state.  As  a  rule  such  an  attack  lasts  one  or  two  days, 
though  it  may  last  a  week,  two  weeks,  or  even  longer. 

Occasionally  a  nocturnal  epilepsy  is  substituted  by  a  psychic 
attack.  In  such  instance  the  patient  may  have  an  outburst 
of  terror  or  of  a  short  delirium,  or  the  attack,  in  rare  instances, 
assumes  the  form  of  a  somnambulism.  The  patient  may  leave 
his  bed,  walk  about,  and  perform  various  complex  acts  of  which 
he  will  subsequently  have  no  recollection.     The  somnambu- 


254  MENTAL    DISEASES 

lism  of  epilepsy,  however,  is  much  less  complete  and  prolonged 
than  that  met  vnth  in  hysteria. 

It  is  probable  that  among  the  mental  phenomena  of  epilepsy 
we  should  include  some  forms  of  double  consciousness.  There 
are  instances  in  which  the  patient  passes  into  a  dazed  condition, 
in  which  he  performs  a  series  of  complex  acts,  buys  railroad 
tickets,  travels,  makes  purchases,  and  conducts  himself  in  such 
a  way  as  not  to  attract  special  attention,  and  finally  comes  to 
himseK  in  a  distant  place,  without  any  knowledge  of  how  he 
arrived  there  or  of  any  intervening  events.  Cases  of  prolonged 
duration  are,  how^ever,  excessively  rare,  and  the  possibility  of 
hysteria,  of  fraud,  of  purposive  deception  must  always,  in  such 
instances,  be  borne  in  mind.  Especially  is  this  the  case  when 
no  previous  history  of  epilepsy,  when  none  of  the  other  psychic 
or  physical  manifestations  or  stigmata  are  present. 

HYSTERIA 

It  may  be  properly  questioned  whether  hysteria  has  really  a 
place  in  a  text-book  on  mental  disease.  However,  so  much 
misapprehension  and  confusion  exist  in  regard  to  the  subject 
as  to  necessitate  a  presentation  of  the  facts.  In  the  first  place, 
hysteria  must  be  clearly  differentiated  from  the  fatigue  neurosis, 
neurasthenia,  with  which  it  has  nothing  in  common.  It  may 
exist  without  the  presence  of  a  single  fatigue  symptom,  just 
as  it  constantly  exists  without  the  presence  of  a  single  organic 
lesion.  Again,  it  must  be  sharply  differentiated  from  hypo- 
chondria. In  the  latter  there  is  a  characteristic  symptom-group, 
appearing  most  frequently  in  men,  in  which  the  patient  has  an 
all-convincing  sense  of  illness,  the  cause  of  which  he  usually 
refers  either  to  his  digestive  tract  oj  to  his  sexual  organs.  (See 
Part  II,  Chapter  III.)  Space  will  not  permit  of  a  consideration 
in  this  section  of  either  gastro-intestinal  or  sexual  hypochondria, 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     255 

but,  suffice  it  to  say  that  there  is  never  present  a  single  stigma 
of  hysteria,  mental  or  physical. 

With  equal  force  must  hysteria  be  differentiated  from  the 
neurasthenic-neuropathic  symptom-groups,  the  psychasthenias, 
considered  in  Chapter  VI,  though  the  Freudian  school  has  hope- 
lessly confounded  the  two  conditions.  Hysteria,  as  a  matter 
of  fact,  bears  no  relation  to  the  fixed  symptoms,  the  phobias, 
the  indecisions,  the  irresistible  impulses  of  psychasthenia,  bears 
no  relation  to  the  special  form  of  neuropathy  presented 
nor  to  the  accompanying  neurasthenia.  It  should  not  be 
necessary  to  point  out  that  the  mere  fact  of  a  nervous  symp- 
tom being  obscure  or  not  understood  does  not  justify  our 
terming  it  hysteric. 

What  then  is  hysteria?  Space  and  the  objects  of  the  present 
volume  forbid  more  than  an  allusion  to  the  origin  of  the  name. 
The  latter  is  derived  from  the  Greek  word  for  uterus,  haripa 
(hystera),  and  is  based  upon  the  idea  of  a  causal  relation  between 
the  uterus  and  the  symptoms.  The  early  Greeks  believed  that 
during  a  hysteric  attack  the  uterus  becomes  detached  from  its 
moorings  and  goes  wandering  about  the  body  seeking  sexual 
satisfaction.  It  is  interesting  to  note  that  in  our  own  day,  while 
the  crude  theory  of  the  wandering  uterus  has  been  abandoned, 
ideas  as  to  the  sexual  origin  of  hysteria  have  persisted.  Un- 
satisfied passion,  repressed  sexual  desire,  unrequited  love, 
genital  irritation,  and  lastly,  repressed  memories  of  sexual 
peccadillos  in  childhood  have  all  had  their  advocates;  and  it  is 
likewise  only  in  relatively  recent  times  that  the  idea  that  hys- 
teria is  dependent  upon  disease  of  the  uterus  or  ovaries  has  been 
abandoned.  Happily,  however,  it  is  no  longer  necessary  to  point 
out  that  hysteria  is  uninfluenced  by  pelvic  surgery  and  that  it 
occurs  in  the  male  as  well  as  in  the  female. 

Hysteria  is  an  independent  nervous  affection.     What  is  its 


256  MENTAL    DISEASES 

nature?  If  we  examine  its  symptoms,  we  are  at  once  impressed 
by  the  fact  that  they  are  of  psychic  origin.  Thus,  we  dis- 
cover in  a  patient  an  anesthesia.  If  we  outline  the  area  in- 
volved, we  find  that  it  bears  no  relation  either  to  the  distribu- 
tion of  the  nerves  or  to  the  sensory  representation  in  the  spinal 
segments.  Quite  commonly  the  loss  of  sensation  embraces 
an  area  covering  a  hand  and  arm  like  a  glove,  or  a  foot  and  leg 
like  a  stocking.  Evidently  such  a  loss  is  not  in  keeping  with 
any  known  fact  of  anatomy.  Finally,  it  may  come  and  go, 
shift  in  distribution,  or  vary  in  intensity.  The  only  possible 
inference  is  that  such  a  symptom  is  mental,  i.e.,  psychic  in 
origin. 

The  French  have  elaborately  studied  hysteria,  and  it  is  due 
to  Charcot,  his  pupil  Gilles  de  la  Tourette,  and  their  followers 
that  we  to-day  possess  an  adequate  picture  of  its  symptoma- 
tology. The  symptoms  may  be  conveniently  divided  into 
sensory,  motor,  somatic,  and  psychic.  A  summary  of  them 
only  can  be  attempted  here. 

The  sensory  symptoms  consist  of  anesthesia,  hypesthesia, 
and  hyperesthesia  or  hyperalgesia.  The  anesthesia  may  pre- 
sent itself,  as  above  described,  as  a  glove-like  or  stocking-like 
anesthesia;  it  may  involve  merely  a  segment  of  a  limb,  when 
it  is  known  as  a  segmental  anesthesia;  it  may  be  limited  to  an 
irregular  patch  upon  the  trunk,  limbs,  or  head,  and  constitute 
a  geometric  anesthesia;  it  may  involve  the  entire  half  of  the 
body,  forming  a  hemianesthesia.  More  frequently  than  anes- 
thesia, there  is  merely  a  diminution  of  sensation,  a  hjrpesthesia 
involving  like  areas. 

Instead  of  a  loss  or  partial  lessening  of  sensation  the  latter 
may  be  increased;  i.  e.,  there  may  be  present  a  hyperesthesia 
or  a  hyperalgesia.  Simple  hyperesthesia  may  in  its  distri- 
bution resemble  anesthesia  or  hypesthesia.     Sometimes  it  is 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     257 

widely  spread  over  a  limb  or  over  one  side  of  the  body  or  por- 
tion of  the  body;  for  instance,  over  the  back  in  traumatic  cases. 
Most  frequently,  however,  when  the  symptom  is  pronounced, 
it  manifests  itself  in  the  form  of  isolated  and  oval-shaped 
patches  of  sensitiveness.  These  patches  may  be  found  upon 
any  portion  of  the  trunk  or  limbs,  though  they  are  most  fre- 
quently met  with  in  certain  situations;  more  especialty  as  a 
small  oval  area  over  the  ribs,  just  below  the  mammary  gland, 
so-called  inframammary  tenderness;  as  a  small  oval  area  im- 
mediately above  the  groin,  so-called  inguinal  or  ovarian  tender- 
ness; as  small  spots  or  areas  over  the  spine,  so-called  spinal 
tenderness;  as  a  small  area  to  one  or  other  side  of  the  spine 
below  the  inferior  angle  of  the  scapula.  Painful  areas  are  also 
met  with  in  spots  no  larger  than  the  tip  of  the  finger  on  the 
scalp;  also  on  the  mucous  membrane  of  the  buccal  and  nasal 
cavities  and  of  the  rectum  and  vagina. 

The  motor  symptoms  of  hysteria  manifest  themselves  in 
the  form  of  paralysis,  of  tremor,  of  incoordination,  of  contrac- 
tion, and  of  convulsive  movements.  As  in  the  case  of  the 
sensory  symptoms,  the  palsies  bear  no  relation  to  the  facts  of 
anatomy;  thus,  there  is  never  a  palsy  of  one  muscle  or  of  a 
group  of  muscles,  such  as  an  eye-muscle  or  of  the  exten- 
sors in  wrist-drop,  but  the  paralysis  involves  the  limb  as  a 
whole.  Further,  when  we  examine  the  limb,  we  usually  find 
that  sensation  also  has  been  lost;  i.  e.,  there  has  been  paralysis 
of  both  motion  and  sensation;  the  entire  limb  has  been 
elided  from  consciousness.  As  in  the  case  of  the  sensory 
phenomena,  the  mental  origin  of  the  symptom  is  clearly 
evident.  The  same  truth  is  discernible  in  the  motor  phe- 
nomena other  than  the  palsies,  but  these  we  will  not  pause 
to  consider. 

The  somatic  or  visceral  symptoms  of  hysteria  consist  of  such 
17 


258  MENTAL    DISEASES 

phenomena  as  loss  of  appetite,  vomiting,  rapid  pulse,  vasomotor 
changes,  rapid  breathing,  cough,  yawTiing,  aphonia,  retention 
of  urine,  anuria,  polyuria,  phantom  tumor.  Each  and  every  one 
of  these  symptoms,  when  analyzed,  reveals  a  psychic  origin. 
Thus  the  vomiting  is  never  attended  by  the  signs  of  organic 
disease;  there  is  no  evidence  of  gastric  catarrh,  ulcer,  malig- 
nant disease,  or  dilatation,  nor  is  there  any  evidence  of  some 
such  purely  physiologic  cause  as  pregnancy.  Again  the  symp- 
toms can  be  relieved  by  suggestion  or  perhaps  conquered  by 
massive  feeding. 

The  psychic  phenomena  of  hysteria  are  not  only  the  under- 
lying phenomena  that  stand  in  causal  relation  to  all  of  the 
others,  but  they  are  the  phenomena  which  most  of  all  concern 
us  here.  The  objective  symptoms  were,  as  already  stated, 
adequately  described  by  Charcot  and  by  Gilles  de  la  Tourette. 
These  investigators  also  laid  great  stress  upon  the  increased 
susceptibility  to  suggestion  in  hysteria,  but  it  remained  for 
Babinski  to  point  out  that  the  symptoms  have  their  origin  in 
suggestion,  in  suggestion  that  may  arise  from  causes  within  as 
well  as  from  causes  wdthout  the  patient.  Babinski  also  main- 
tains that  the  sensory  losses  of  hysteria  are  always  the  outcome 
of  inadvertently  made  suggestions  at  the  time  the  patient  is 
examined  by  the  physician.  He  claims,  for  instance,  that  the 
reason  hysteric  hemianesthesia  predominates  on  the  leftside 
of  the  body  is  because  the  physician  being  usually  right- 
handed,  has  the  brush  or  esthesiometer  in  his  right  hand,  and 
naturally  tests  the  left  side  of  the  patient's  body  first,  thus  sug- 
gesting the  anesthesia  which  he  is  trying  to  discover.  In  one 
hundred  consecutive  cases  of  hysteria,  w^hich  had  not  been  pre- 
viously examined  by  other  physicians,  he  failed,  with  due  pre- 
cautions, to  discover  hemianesthesia.  It  is  interesting  also  to 
add  that  anesthesia  of  the  special  senses,  contraction  of  the 


MENTAL    DISEASE   RELATED    TO    SOMATIC    AFFECTIONS     259 

visual  field,  deafness,  loss  of  taste  and  smell  may  also  be  found 
on  the  anesthetic  side,  doubtless  due  to  a  spreading  of  the 
suggestion  of  sensory  loss. 

Just  as  the  symptoms  of  hysteria  are  produced  by  suggestion, 
so  are  they  commonly  removed  by  suggestion,  and  because  of 
this  fact  Babinski  has  devised  the  name  pithiatism  (rret'w,  "I 
persuade,"  and  IdwiJ-at,  "I  cure"),  curable  by  persuasion. 

Hysteria,  as  we  have  seen,  may  be  attended  by  physical 
signs  which  may  simulate  organic  disease,  but  this  simulation 
is  imperfect,  and  there  usually  is  Httle  difficulty  in  making  the 
differentiation.  Thus,  the  palsies  and  the  sensory  losses  im- 
press us  with  their  unreality  and  unessential  character;  there 
is  something  about  the  case  which  even  to  the  layman  suggests 
its  real  nature.  Equally  is  this  true  of  mental  symptoms  when 
they  are  present.  The  simulation  of  mental  disease  is  grossly 
imperfect.  At  most,  states  of  excitement  suggesting  delirium 
or  confusion  are  met  with,  and  here,  as  in  the  case  of  the  physi- 
cal signs,  the  symptoms  have  the  appearance  of  something 
that  is  not  genuine,  of  something  assumed,  of  something  vol- 
untarily and  artificially  produced;  in  short,  as  possessing  a 
factitious  character. 

Let  us  turn  our  attention  to  the  hysteric  paroxysm  and  the 
attendant  mental  phenomena.  Usually  the  attack  is  preceded 
by  a  prodromal  period,  extending  over  a  number  of  minutes, 
several  hours,  or,  it  may  be,  over  a  day  or  two.  During  this 
period  the  patient  frequently  becomes  depressed,  avoids  the 
members  of  her  household,  is  uncommunicative,  irritable,  and 
perhaps  is  angry  or  weeps  upon  slight  provocation.  Less  fre- 
quently the  patient  is  excited,  restless,  perhaps  a  little  exuberant 
or  even  boisterous,  or  she  may  laugh  and  weep  by  turns.  Less 
frequently  still,  she  acts  as  though  she  had  frightening  visions, 
saw  strange  faces  and  objects.    Very  commonly  she  complains 


260  MENTAL    DISEASES 

of  choking  sensations,  clutches  at  her  throat,  says  that  she  can- 
not breathe,  has  headache  or  other  distressing  feelings.  A 
picture  suggesting  a  frank  delirium  is  rarely  observed.  Sooner 
or  later  a  convulsion  comes  on.  The  convulsion  is  attended 
by  a  tonic  spasm,  during  which  the  patient  may  present 
rigidity  of  all  of  the  muscles  of  the  limbs  and  trunk;  at 
times,  indeed,  an  opisthotonos,  an  "arc  de  cercle,"  may  be 
present.  Soon,  however,  the  tonic  spasm  is  followed  by  clonic 
movements,  which  are  much  greater  in  extent  than  those  seen 
in  epilepsy  and  of  themselves  usually  suggest  a  volimtary  char- 
acter. Hysteric  attacks  are  of  variable  duration;  some  are 
brief,  others  more  prolonged,  and  in  the  latter  the  patient  may 
contort  the  body  into  various  bizarre  positions,  or  may  make 
gestures  and  movements  clearly  expressive  of  volition  and 
purpose.  Sometimes  the  patient  tears  her  clothing,  dishevels 
her  person,  assumes  dramatic  and  passionate  attitudes,  shrieks 
and  weeps.  Little  by  little  she  becomes  quiet,  submits  to  the 
ministrations  of  her  friends,  and  conducts  herself  normally  or 
perhaps  goes  to  sleep. 

It  is  characteristic  of  the  hysteric  attack  that  the  patient 
does  not  lose  consciousness,  a  fact  that  is  rarely  admitted  by  the 
patient,  but  commonly  capable  of  convincing  proof;  some- 
times the  fact  that  the  patient  is  conscious  during  the  attack 
is  self-evident.  The  patient  never  hurts  herself  and  betrays 
by  her  actions  or  by  her  subsequent  statements  a  knowledge 
of  her  envirormient.  The  sphincter  control  is  never  lost,  nor 
is  there  ever  any  biting  of  the  tongue  as  in  epilepsy. 

Instead  of  subsiding,  the  attack  may  pass  into  a  phase  in 
which  the  patient  seems  to  hear  voices,  to  see  visions,  and  in 
which  she  utters  disconnected  phrases,  is  exalted,  depressed, 
erotic,  obscene.  At  other  times,  the  patient  appears  to  pass 
into  a  condition  resembling  somnambulism.    Contrasted  with  a 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     261 

delirium  due  to  an  infection  or  an  intoxication,  a  crass  differ- 
ence becomes  apparent.  The  visions  which  the  patient  sees, 
and  which  she  dramatically  addresses,  give  the  bystander  the 
impression  of  being  assumed,  not  genuine.  The  illusions  of 
persons  and  objects  are  often  exhibited  in  such  a  way  as  to  give 
rise  to  the  same  conviction.  The  patient,  being  told  that  a 
certain  person  is  her  father,  dramatically  calls  him  by  a  strange 
name,  and  yet  a  moment  later  betrays  that  she  knows  exactly 
who  the  designated  person  is.  Finally,  neither  the  incoher- 
ence nor  the  delusions  recall  those  of  deUrium  proper.  Long 
sentences  and  long  phrases,  at  all  times  with  a  rich  emotional 
content,  replace  the  unrelated  fragments  uttered  in  the  genuine 
affection. 

The  duration  of  the  attack  is  usually  quite  short,  sometimes 
a  few  minutes,  sometimes  a  few  hours,  rarely  a  day  or  more. 
Sometimes  it  merges  into  a  confusion.  A  mild  confusion, 
spoken  of  sometimes  by  German  writers  as  a  "Daemmerzus- 
tand,"  a  twilight  state,  is  among  the  rarer  conditions  met  with. 
It  may  follow  a  convulsive  attack  or  may  come  on  independ- 
ently. It  is  usually  of  short  duration,  a  few  minutes  or  hours; 
rarely  it  recurs  with  interruptions  of  lucid  intervals  for  longer 
periods. 

A  hysteric  attack  may  eventuate  in  a  stupor;  i.  e.,  in  a 
hysteric  sleep  or  coma.  Such  a  stupor  or  sleep  may  come 
on  independently,  or  it  may  recur  at  intervals  and  may  simulate 
a  narcolepsy.  The  sleep  is  of  variable  duration,  extending  from 
a  fraction  of  an  hour  to  several  hours,  sometimes  to  a  day  or 
more. 

In  some  cases  a  serious  and  persistent  mental  disorder  super- 
venes in  a  chronic  form.  Based  either  upon  auto-suggestions, 
themselves  the  outcome  of  visceral  sensations,  or,  it  may  be, 
upon  suggestions  received  from  without,  the  patient  acquires  the 


262  MENTAL    DISEASES 

belief  that  she  is  ill.  She  becomes  introspective.  Her  symptoms 
become  greatly  exaggerated.  She  becomes  self-absorbed,  her 
craving  for  sympathy  becomes  more  pronounced,  and  she  con- 
stantly demands  medical  attention.  She  develops  a  memory  that 
is  painful  in  its  minuteness,  and  recites  and  repeats  with  evident 
satisfaction  the  account  of  her  various  symptoms  and  affections, 
and  retails  with  endless  elaboration  her  experiences  with 
various  physicians  and  various  cures.  Such  a  patient  is  not 
happy  unless  she  is  imder  a  physician's  or  surgeon's  care. 
Sometimes  the  list  of  operations  through  which  she  has  passed 
is  appalling,  and  may  include  in  one  and  the  same  case 
removal  of  the  appendix,  of  the  ovaries,  of  the  uterus,  excision 
of  the  coccyx,  sewing  fast  one  or  both  kidneys.  Such  patients 
are  among  the  most  difficult  with  which  the  physician  has  to  deal. 
The  fact  that  so  crass  a  symptom  as  hemianesthesia  can  be 
developed  in  one  individual  by  suggestion,  and  that  suggestion 
in  another  individual  fails  altogether  to  ehcit  this  symptom 
or,  indeed,  any  other,  is  proof  that  in  the  one  there  is  pre-existing 
an  abnormal  condition  which  is  clearly  absent  in  the  other;  and 
this  is  a  pathologic  susceptibihty  to  suggestion.  The  inference  is 
obvious;  hysteria  is  the  expression  of  a  neuropathy  whose  cardi- 
nal feature  is  feebleness  or  absence  of  resistance  to  suggestion. 
The  neuropathic  individual  accepts,  the  normal  individual 
repels,  the  suggestion.  Hysteria  is  an  inborn,  an  inherent 
neuropathy,  one  that  depends  upon  the  innate  organization 
of  the  individual,  and  the  symptoms  of  which  may  be  developed 
by  any  incidental  factor  which  may  act  as  a  suggestion.  Further, 
just  as  the  reaction  of  the  hysteric  individual  to  suggestion  is 
excessive  and  pathologic,  so  is  his  reaction  to  emotional  stimuli 
excessive  and  pathologic.  Exaggerated  emotional  reaction, 
exaggerated  emotional  expression,  general  emotional  instability, 
are   therefore   likewise   features   of   the   hysteric   neuropathy. 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     263 

In  keeping  with  this  fact,  the  hysteric  individual  reacts  inordi- 
nately to  fright,  joy,  annoyance,  anger,  disappointment,  mortifi- 
cation, fancied  slights  or  wrongs,  shame  and  kindred  incidents. 
It  follows  as  a  physiological  corollary  that  the  outward  expression, 
the  physical  reaction,  is  excessive.  Finally,  hysteria  is  a  neurop- 
athy of  degeneracy  and  in  keeping  with  this  fact  it  presents 
a  large  element  of  heredity.  Indeed,  Charot  and  his  pupils 
regarded  hysteria  as  always  inherited;  all  other  causes,  to  use 
Charcot's  expression,  have  merely  the  value  of  agents  provoc- 
ateurs. 

The  personality  of  the  hysteric  is  a  vulnerable  one;  an  entire 
limb,  one  half  of  the  body,  may  be  ehded  from  his  consciousness; 
at  another  time  a  veritable  cleavage  of  the  personality  may 
occur.  As  has  just  been  stated,  a  hysteric  seizure  may  eventu- 
ate in  an  attack  of  somnambulism ;  on  the  other  hand,  an  attack 
of  somnambulism  may  come  on  spontaneously.  In  this  state 
the  patient  may  perform  automatically  various  acts,  often  com- 
plex in  their  nature,  requiring  considerable  time,  and  bearing 
no  relation  to  the  occasion  or  to  the  environment,  and  during 
the  performance  of  which  the  patient  is,  to  all  intents  and  pur- 
poses, oblivious  of  his  surroundings.  Such  attacks  usually 
terminate  quite  suddenlj^,  the  patient  subsequently  claiming 
to  have  no  recollection  of  what  has  occurred.  Such  symptoms, 
when  genuine,  can  only  be  accounted  for  on  the  basis  of  a 
psychic  dissociation.  One  group  of  ideas,  as  in  the  somnam- 
bulism of  hypnosis,  occupies  the  field  of  consciousness  to  the 
complete  exclusion  of  all  others;  i.  e.,  there  is  a  separation  of 
the  personahty  into  two  parts  which  have  no  relation  with  each 
other.    (See  Part  III,  Chapter  I.) 

The  cleavage  of  the  personality  may  be  still  more  complete,  so 
that  the  patient  for  long  periods  of  time  acts  exclusively  under 
the  influence  of  one  group  of  ideas  and  associations,  and,  at 


264  MENTAL    DISEASES 

others,  of  another  group,  and  conducts  himself  as  though  he 
were  possessed  of  two  personalities.  While  in  one  state  he 
has  no  knowledge  or  recollection  of  his  actions,  thoughts,  and 
experiences  in  the  other.  One  morning  a  young  physician 
left  his  office  to  go  to  a  hospital,  with  the  outdoor  service  of 
which  he  was  connected.  He  did  not  appear  at  the  clinic, 
nor  was  anything  heard  of  him  for  two  days.  He  suddenly 
came  to  himself  on  a  country  road,  many  miles  from  his  home. 
He  had  no  idea  of  where  he  was,  or  how  he  had  gotten  to  the 
place  at  which  he  found  himself.  He  had  evidently  purchased 
a  ticket,  boarded  a  train,  gone  to  a  hotel,  paid  for  food  and 
lodging;  he  had  also  apparently  lost  his  straw  hat,  for,  when 
he  came  to  himself,  he  was  wearing  a  cap;  the  latter  was 
new,  and  it  may  be  properly  inferred  that  he  had  purchased  it. 
Evidently  he  had  committed  no  act  which  had  been  unusual, 
and  nothing  in  his  demeanor  had  attracted  attention.  The 
case  of  Ansell  Bourne,  reported  by  William  James,  is  even  more 
interesting,  because  the  change  to  the  abnormal  personality 
was  of  longer  duration  and  more  complete.  The  patient  was 
an  itinerant  preacher,  who  disappeared  one  morning  from  his 
home  in  Providence  and  reappeared  two  months  later  in  Nor- 
ristown,  where,  under  a  new  name,  he  had  conducted  a  small 
stationery  store.  He  came  to  himself  suddenly  in  a  fright  and 
asked  to  know  where  he  was.  The  case  studied  by  Morton 
Prince,  and  the  story  of  which  is  related  by  the  patient  herself, 
reveals  a  still  more  remarkable  instance  of  a  dissociated  or 
disintegrated  personaUty.  Regarding  some  of  the  reported 
cases,  however,  a  legitimate  doubt  of  their  genuineness  may  be 
entertained.  Hysteric  people  often  like  to  be  interesting,  and 
enjoy  occupying  the  center  of  the  stage.  That  they  practice 
gross  deceptions  in  order  to  secure  the  sympathy  and  attention 
which  they  crave,  every  hospital  physician  knows.     That  they 


MENTAL   DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     265 

will  simulate  anuria,  rise  of  temperature,  or  what  not,  that  they 
will  undergo  severe  procedures,  face  painful  operations,  in 
order  to  achieve  this  end  is  a  matter  of  common  knowledge. 
That  they  may  lie  concerning  so  interesting  a  phenomenon  as 
double  personality  is  extremely  probable.  Further,  human 
motive  is  sometimes  very  obscure,  and  the  reason  may  not 
always  be  apparent  why  a  man  should  conduct  himself  in  a 
maimer  suggesting  that  there  is  a  motive  for  concealing  himself 
or  possibly  for  making  an  entirely  new  start  in  life  under  entirely 
new  conditions.  Unfortunately,  too,  it  is  not  always  possible 
to  separate  truth  from  falsehood,  and  in  no  case  is  this  more 
difl&cult  than  in  hysteria.  The  remarkable  experience  of 
Ernest  Hart  with  some  of  Charcot's  patients  may  be  recalled 
by  some  of  my  older  readers. 

In  conclusion,  it  may  be  said  that  hysteric  mental  disorders 
are,  on  the  whole,  infrequent.  This  is  true  alike  of  delirium 
and  confusion,  while  somnambulism,  and  especially  double 
personality,  are  decidedly  rare. 

CHOREA 

Pronounced  mental  phenomena  are  rare  in  chorea.  How- 
ever, the  choreic  child  is  often  slow  and  heavy,  and  sometimes 
hebetude  and  apathy  are  expressed  by  the  features.  If  the 
chorea  be  very  severe  and  prolonged,  these  symptoms  may  be- 
come more  pronounced,  and  the  child  may  be  quite  stupid  and 
may  reply  to  questions  with  difl&culty  and  in  monosyllables. 
In  the  older  patients,  especially  in  girls  about  the  age  of  puberty, 
a  mild  or  a  decided  confusion,  with  hallucinations,  may  make  its 
appearance.  Rarely,  e.  g.,  in  chorea  occurriag  during  or  follow- 
ing pregnancy,  an  active  dehrium  supervenes.  Such  cases, 
spoken  of  as  chorea  insaniens,  are  usually  very  ill,  the  choreic 
movements  pronounced,  and  the  exhaustion  severe.  Death  is 
a  not  infrequent  outcome. 


266  MENTAL    DISEASES 

Cases  of  Huntingdon's  chorea  now  and  then  develop  mental 
symptoms.  The  patient  becomes  forgetful,  depressed,  and 
irritable,  and  at  times  slightly  confused  and  hallucinatory. 
Less  frequently  he  becomes  suicidal  and  still  less  often  perse- 
cutory. A  mild  dementia,  which  becomes  more  marked  with 
time,  is  not  uncommon.  Notwithstanding,  there  are  cases  of 
many  years'  duration  in  which  the  mental  condition,  despite 
the  distressing  affection,  is  fairly  well  preserved. 

PARALYSIS  AGITANS 
Mental  symptoms  are  very  infrequent  in  paralysis  agitans. 
However,  depression  is  now  and  then  met  with,  though  it  is 
remarkable  how  well  the  majority  of  the  patients  bear  their 
affliction.  Now  and  then  a  mild  confusion  is  noted.  Some- 
times hallucinations  are  present.  One  of  my  patients  saw 
black  objects,  which  she  took  to  be  mice,  darting  across  the 
walls  and  ceiling  and  which  frightened  her  very  much.  Very 
rarely  are  there  hallucinations  of  the  other  senses.  Hallucina- 
tions of  taste  have  been  described. 

B.    ORGANIC  NERVOUS  DISEASES 
PARESIS 

Paresis  is  an  affection  which  is  not  usually  classified  among 
nervous  diseases.  However,  while  the  mental  symptoms  form 
a  prominent  part  of  the  clinical  picture,  the  affection  is  attended 
by  profound  organic  changes.  These  changes  involve  not  only 
the  brain,  but  also  the  spinal  cord  and,  in  given  instances,  even 
the  nerves.  Sometimes,  again,  the  early  symptoms  are  purely 
peripheral,  while  cerebral  and  mental  symptoms  make  their 
appearance  relatively  late.  In  the  great  majority  of  cases,  how- 
ever, mental  sjTnptoms  appear  earl3\  At  first  they  are  exceed- 
ingly ill-defined,  vague,  and  general,  and  in  keeping  with  the 


MENTAL   DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     267 

fact  of  a  diffuse  involvement  of  the  brain.  In  its  essential 
features,  paresis  consists  of  a  slowly  oncoming  and  progressive  de- 
mentia, which  is  attended  by  certain — and,  it  may  be  added, 
in  their  ensemble — characteristic  physical  signs. 

It  is  known  by  a  number  of  synonyms,  among  which  may  be 
mentioned  general  paralysis  of  the  insane,  paralytic  dementia, 
paretic  dementia,  progressive  general  paralysis,  general  paresis, 
and  paresis.  The  name  paresis  is  now  in  common  use,  and, 
being  a  mononym,  is,  on  the  whole,  to  be  preferred. 

Etiology. — An  increasing  knowledge  of  paresis  has  enabled 
us  to  fasten  with  certainty  upon  one  and  the  sole  factor  as  the 
cause,  namely,  syphilis.  It  is  true  that  a  percentage  of  cases 
exists  in  which  no  history  of  syphilis  can  be  obtained,  or  indeed 
of  any  venereal  infection  whatever.  We  must  remember, 
however,  that  many  cases,  by  the  time  the  clinical  examination 
is  made,  are  already  so  far  advanced  that  their  statements  as  to 
their  past  history  are  no  longer  trustworthy.  Further,  that 
the  initial  lesion  may  be  relatively  slight  and  insignificant  and 
may  thus  escape  detection  or  recognition  is  well  known.  Es- 
pecially may  this  be  the  case  when  the  lesion  occurs  extra- 
genitally  and  innocently.  The  fact  that  paretics,  without 
exception,  are  wonderfully  tolerant  of  iodids  and  mercurials 
is  a  fact  of  great  clinical  value.  Further,  the  Wassermann 
reaction  is  positive  in  almost  100  per  cent,  of  the  cases 
in  the  blood,  and  90  per  cent,  in  the  cerebrospinal  fluid  with 
0.2  c.c.  and  fully  100  per  cent,  when  relatively  large  quantities 
of  the  latter  are  used  (Nonne,  Hoche).  Finally,  the  epoch- 
making  discovery  of  the  Treponema  pallidum  in  the  brains  of 
paretics  by  Noguchi  forms  the  last  link  in  the  chain  of  evidence. 
Noguchi's  discovery  has  since  been  many  times  confirmed. 
Among  the  earlier  observers  were  Marinesco,  Marie,  Levaditi 
and  Bankowski,  and  Foerster  and  Tomasczewski.    The  latter, 


268  MENTAL    DISEASES 

indeed,  demonstrated  the  presence  of  living  spirochetes  in 
material  obtained  from  paretics  by  brain  puncture,  while 
Noguchi  successfully  inoculated  rabbits  with  the  substance  of 
paretic  brains,  typical  syphilitic  lesions  being  produced.  The 
statement  can  now  be  definitely  made  that  without  a  previous 
syphilis  there  can  be  no  paresis. 

A  moment's  reflection  calls  to  mind  that  of  those  who  are 
the  victims  of  syphilitic  infection,  only  a  percentage,  and  a 
rather  small  percentage  at  that,  develops  paresis.  It  is  evident, 
therefore,  that  other  contributing  and  predisposing  factors 
must  play  a  role.  Among  these  are  overwork,  nervous  over- 
strain, exhaustion  of  any  origin  whatever.  Some  years  ago 
Edinger  pointed  out  that,  in  order  that  the  integrity  of  nervous 
structures  should  be  maintained,  there  must  be  a  proper  balance 
between  the  consumption  of  nerve  substance  (as  a  result  of  its 
functional  exercise)  and  the  restitution  or  upbuilding  of  that 
nerv^e  substance.  That  this  balance  is  disturbed  in  the  tabetic 
and  the  paretic  is  extremely  likely,  and  probably  this  in  a 
measure  explains  the  role  which  nervous  overwork  and  over- 
strain plays  in  the  development  of  paresis.  A  far  more  potent 
reason,  however,  is  to  be  found  in  the  fact  that  exhaustion 
diminishes  the  defensive  reactions  of  the  organism,  lessens  its 
antitoxin-forming  power,  and  thus  favors  both  an  increasing 
invasion  and  an  increasing  propagation  of  the  parasite.  It  is 
doubtless,  also,  for  a  similar  reason  that  paresis  commonly 
appears  only  as  the  patient  approaches  the  forties  and  fifties; 
that  is,  when  his  biological  resistance  begins  to  flag,  when  the 
vigor  of  his  metabolic  processes  begins  to  give  way;  and  this 
too  in  patients  in  whom  the  infection  has  been  acquired  many 
years  before  and  in  whom  the  individual  has  been  the  host  of 
the  germ  for  ten,  fifteen,  twenty,  twenty-five,  or,  it  may  be, 
even  forty  years. 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     269 

Alcoholism,  because  it  likewise  lessens  the  defensive  forces, 
is  also,  in  many  cases,  a  powerful  contributing  factor.  The 
same  value  must  be  assigned  to  such  factors  as  exhaustion  from 
previous  iUness  and  from  sexual  excess.  Regarding  trauma, 
it  may  be  definitely  stated  that  the  relation  between  it  and 
paresis  is  that  of  sequence  only.  It  is  conceivable  that  infection 
of  the  nervous  system  having  once  been  established,  trauma  may 
prove  very  injurious,  as  the  resistance  of  the  paretic  is  greatly 
diminished.    Trauma,  however,  cannot  cause  paresis. 

Paresis  has  an  interesting  geographic  distribution;  thus,  it 
is  common  in  England,  France,  Germany,  America,  Italy,  and 
the  Slavic  countries;  it  is  rare,  or  relatively  so,  in  Scandinavia, 
Iceland,  Ireland,  the  IMohammedan  countries,  and  India.  Per- 
haps this  is  to  be  explained  by  a  relatively  greater  strain  and 
intensive  living.  In  America,  again,  paresis  is  quite  frequent 
among  negroes.  That  certain  races  possess  a  greater  susceptibility 
is  proven,  as  pointed  out  by  Kraepelin,  by  the  fact  that  in  Java 
and  Algiers,  Europeans  suffer,  as  compared  with  the  natives,  dis- 
proportionately from  paresis,  and  the  same  is  true  of  foreigners 
as  compared  with  the  natives  in  Bosnia.  The  significance  of 
these  facts  is  somewhat  doubtful.  It  is  conceivable  that  the 
more  susceptible  races  have  acquired  a  lessened  resistance 
as  a  result  of  their  method  of  living — an  overstrenuous  civil- 
ization, an  abuse  of  alcohol,  or  some  other  as  yet  unascertainable 
cause.  However,  certain  facts  suggest  that,  at  times  at  least,  the 
virus  of  syphiHs  undergoes  some  change,  acquires  some  quality 
which  especially  favors  the  development  of  paresis.  It  is  difiicult 
otherwise  to  account  for  instances  in  which  husband  and  wife 
both  suffer  from  paresis,  or  in  which  a  number  of  men  having 
acquired  syphilis  from  the  same  woman,  all  subsequently  develop 
paresis;  the  instance  reported  by  Brosius  of  a  number  of 
glass-blowers,    all   infected  by  the  use  of  the   same   mouth- 


270  MENTAL    DISEASES 

piece,  and  of  whom  more  than  half  became  either  tabetic  or 
paretic,  illustrates  the  same  fact.  Certainly  such  occur- 
rences as  these  can  hardly  be  accounted  for  on  the  basis 
of  coincidence. 

Among  other  important  facts,  it  must  be  added  that  paresis 
is  relatively  more  common  in  cities  than  in  rural  districts; 
also,  that  male  patients  largely  predominate.  The  proportion 
of  the  sexes  is  somewhat  variable.  Paresis  occurs  very  infre- 
quently among  women  of  the  upper  class,  and  is  relatively 
frequent  among  men  of  the  same  class.  Among  women  of  the 
lower  classes  the  number  is  much  greater,  though  here  also 
men  still  predominate.  Perhaps  four  to  one  of  all  classes  would 
be  a  fair  approximation. 

Paresis  is  an  affection  which  makes  its  appearance  during 
the  most  strenuous  period  of  adult  life;  that  is,  between  thirty 
and  fifty  years  of  age.  It  is  rare  before  twenty-five  and  rare 
after  sixty.  Its  greatest  frequency  lies  between  thirty-five 
and  forty-five.  It  also  occurs  in  a  juvenile  form,  and  in  such 
cases  is  due  usually  to  inherited  syphilis,  though  it  may  have 
its  origin  in  syphilis  acquired  in  infancy.  Compared  with  the 
adult  form  it  is,  of  course,  rare.  The  ages  of  the  patients  are 
usually  in  the  neighborhood  of  fourteen,  sixteen,  or  eighteen 
years.  Very  exceptionally  juvenile  paresis  occurs  earlier  and 
sometimes  later.  Cases  of  twelve  and  even  eleven  years  of 
age  have  been  reported,  and  Hoche  speaks  of  cases  beginning 
as  early  as  the  fourth  or  fifth  year  of  life. 

Symptoms  and  Course. — The  symptoms  and  course  of  pare- 
sis are  those  of  a  gradually  on-coming  and  slowly-increasing 
dementia;  there  is  a  progressive  mental  and  physical  deteri- 
oration, which  becomes  more  and  more  profound,  and  finally — 
with  doubtful  exceptions — terminates  in  death. 


MENTAL   DISEASE    RELATED   TO    SOMATIC    AFFECTIONS     271 

It  is  quite  common  to  divide  the  course  of  the  affection  into 
a  number  of  stages;  while  there  is  much  justification  for  this, 
it  must  not  be  inferred  that  these  stages  are  clearly  differen- 
tiated from  each  other,  for  this  is  not  the  case.  As  a  matter  of 
fact,  one  stage  merges  insensibly  into  the  other,  and  it  is 
usually  quite  impossible  to  say  definitely  when  one  ends  and 
another  begins.  However,  the  symptoms  vary  both  in  char- 
acter and  in  intensity  at  various  times.  This  is  true  more 
especially  of  the  beginning,  of  the  fully  developed,  and  of  the  final 
periods.  It  is,  therefore,  both  convenient  and  useful  to  con- 
sider the  symptoms  as  related  to  three  stages:  first,  those  of 
the  initial  period,  second,  those  of  the  fully  developed  period^ 
and,  third,  those  of  the  terminal  period. 

The  recognition  of  the  disease  in  its  earliest  beginnings  is 
very  difficult.  The  patient  himself  does  not  realize  that  he  is 
ill,  and  it  is  only  after  symptoms  have  been  present  for  a  time 
that  he  is  brought  to  a  physician  by  relatives  or  friends.  As  a 
rule,  the  statement  is  made  that  he  has  not  been  well  for  several 
months.  The  friends  often  tell  us  that  his  appearance  and 
manner  have  changed,  and  that  he  no  longer  attends  to  his 
business  properly,  or  no  longer  does  his  work  as  well  as  formerly. 
Inaccuracies  and  changes  in  the  quality  of  his  work  are  among 
the  first  symptoms  observed;  it  is  characteristic  that  this  deterio- 
ration is  observed,  not  by  the  patient,  but  by  those  about  him. 

The  patient's  condition  may  suggest  that  he  is  suffering  from 
neurasthenia,  but  a  brief  examination  soon  shows  that  this 
suggestion  is  very  remote.  Rarely  does  the  patient  actively 
complain,  and  there  are  never  present  the  fatigue  aches,  and 
pains  of  neurasthenia.  Such  information  as  we  obtain  from 
the  paretic  in  regard  to  his  bodily  sensations  is  usually  eli'cited 
by  questioning  only.  The  neurasthenic,  as  is  well  known,  not 
only  volimteers  this  information,  but  insistently  dwells  upon 


272  MENTAL    DISEASES 

his  headache,  backache,  and  other  fatigue  pains.  Later,  after 
physical  signs  have  made  their  appearance,  the  differentiation 
from  neurasthenia  becomes  absolutely  certain. 

The  paretic  patient  quite  commonly  looks  tired  and  perhaps 
a  little  somnolent.  Usually  he  is  pale;  at  other  times  he  pre- 
sents a  heightened  color.  Quite  commonly,  too,  his  face  lacks 
its  former  vigor  of  expression.  His  attitude,  his  movements, 
his  walk,  all  may  suggest  a  general  loss  of  tone.  He  does  not 
apprehend  or  comprehend  as  readily  as  formerly.  He  is  absent- 
minded,  cannot  fix  his  attention  as  before,  cannot  follow  a 
prolonged  train  of  thought,  misses  the  point  of  a  conversation, 
loses  the  connection  of  what  is  being  said.  He  may  act  as 
though  there  were  a  sUght  haze  between  himself  and  the  ex- 
ternal world.     Soon  he  becomes  forgetful. 

During  this  time  he  may  sleep  badly.  He  may  fall  asleep 
with  difficulty  and  the  sleep  may  be  broken;  or,  on  the  other 
hand,  he  may  be  somewhat  somnolent  during  the  day.  He 
may  complain — though  rarely — of  fulness,  pressure,  or  con- 
striction about  the  head,  or  of  a  dazed  or  stunned  feeling,  and 
at  other  times  of  dizziness.  Sometimes  he  complains  of  ringing 
in  the  ears,  sparks  before  the  eyes,  or  muscse  volitantes.  Vague 
aches,  suggesting  rheumatism,  may  be  present,  but  more  often, 
if  there  be  pain,  it  assumes  a  tabetic  character,  is  lightning-like 
and  shooting.  Pain  in  the  head  of  great  severity  and  simulat- 
ing migraine  may  also  occur;  at  times  the  pain  is  referred  to  the 
supraorbital  and  adjacent  regions  and  especially  to  the  eyeball. 
Such  an  attack  may  suggest  an  ophthalmic  migraine.  On  the 
whole,  however,  it  should  be  added  that  distressing  and  painful 
sensations  are  infrequent  in  paresis.  Even  the  migraine-like 
attacks,  if  they  occur  at  all,  may  be  limited  to  but  a  few  seizures 
during  the  entire  initial  period. 

Gradually  the  mental  symptoms  become  a  little  more  pro- 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS      273 

nounced.  There  is  an  increasing  difficulty  of  attention.  The 
patient  overlooks  important  matters,  misplaces  objects  and 
papers,  forgets  engagements,  confuses  persons,  perhaps  loses 
himself  in  accustomed  places.  Sometimes  he  acts  as  though 
he  were  slightly  dazed  or  confused,  at  other  times  as  though  he 
were  slightly  intoxicated.  He  may  answer  questions  fairly 
well,  but  may  forget  where  he  is,  the  circumstances  in  which 
he  finds  himself,  or  even  to  whom  he  is  speaking.  He  can  no 
longer  observe  closely  and  he  tires  very  readily.  His  habits 
deteriorate;  he  does  not  dress  himself  completely,  omits  some 
article  of  clothing,  or  does  not  adjust  his  clothing  properly. 
His  conduct,  too,  shows  that  he  is  forgetting  the  decencies  and 
proprieties,  and  that  his  taste,  esthetic  sense,  and  judgment 
are  being  impaired.  His  feelings,  his  sense  of  obligation,  his 
affection  for  his  family  and  friends  become  blunted.  He  may 
become  dull,  apathetic,  and  irritable.  Disorders  of  memory 
become  more  pronounced.  He  forgets  recent  events,  the  death 
of  a  friend,  repeats  himself  in  talking,  cannot  group  past  events 
correctly,  cannot  give  a  clear  consecutive  history  of  his  case. 
His  account  reveals  obvious  lapses  and  lacunae.  Often  the 
latter  are  filled  in  with  purely  fictitious  material.  The  pa- 
tient may  tell  silly  and  absurd  lies  which  have  apparently  no 
object  or  purpose. 

Hand  in  hand  with  the  general  mental  deterioration,  the 
patient  may  become  gross  and  intemperate  in  his  habits.  He 
may  drink  to  excess,  become  coarse  and  obscene  in  speech, 
may  expose  his  person,  attempt  liberties  with  members  of  the 
opposite  sex,  or  may  manifest  eroticism  in  other  ways.  He  may 
also  commit  theft;  frequently  the  object  stolen  can  be  of  no 
use  to  the  patient,  and  the  theft  is  merely  an  evidence  of  his 
absentmindedness  and  increasing  dementia.  At  times  again, 
as  in  the  instance  of  a  forgery,  the  act  is  clearly  the  result  of 

18 


274  MENTAL    DISEASES 

a  deterioration  of  the  moral  sense;  usually  the  offence  is  done 
in  so  silly  and  absurd  a  manner  as  to  lead  to  early  and  certain 
detection. 

The  invasion  of  paresis  is  by  no  means  imiform.  Faint 
signs  of  mental  change  come  and  go,  are  at  times  quite  notice- 
able and  at  others  disappear.  These  variations  of  progress 
are  quite  irregular  in  their  occurrence.  Sometimes,  however, 
they  are  so  clearly  marked  as  to  attract  the  attention  of  friends. 
At  times,  also,  there  is  a  distinct  diurnal  variation,  the  patient 
being  quite  normal  or  almost  so  in  the  morning,  and  becoming 
dull,  heavy,  dazed,  or  slightly  confused  in  the  evening. 

While  the  mental  phenomena  are  making  their  appearance, 
physical  signs  also  become  evident  to  the  observer.  We  have 
already  noted  that  the  patient's  expression  may  be  that  of 
slight  fatigue  or  somnolence,  or  that  he  may  present  an  unusual 
pallor  or  a  heightened  color.  If  we  look  closely,  we  note  also 
that  the  face  presents  a  slightly  smoothed-out  appearance; 
its  folds  and  wrinkles  are  shallower  and  its  lines  less  clearly 
marked.  The  facial  muscles  reveal  the  general  loss  of  tone 
betrayed  by  the  patient  in  his  attitude  and  in  his  movements. 
If  we  observe  his  movements  carefully,  we  note  also  sUght 
inaccuracies  and  slight  incoordinations;  perhaps  a  faint  inten- 
tion tremor  of  the  hands,  lips,  or  tongue;  perhaps  a  slight  and 
inconstant  inequality  of  the  pupils;  or  there  may  be  an  occa- 
sional tremor  or  uncertainty  in  the  speech.  As  the  affection 
progresses,  these  physical  signs,  shadowy  and  uncertain  at  first, 
become  gradually  more  and  more  definite. 

Little  by  little  the  symptoms,  both  mental  and  physical, 
become  more  pronounced,  until  the  patient  enters  into  the  fully 
developed  period  of  the  disease.  As  a  rule,  the  transition  is 
gradual,  and  it  is  impossible  to  say  just  when  the  initial  period 
has  terminated  and  the  established  period  begun.     Sometimes, 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     275 

however,  the  transition  is  relatively  sudden  or  rapid,  as  when 
certain  attacks,  suggesting,  it  may  be,  epilepsy  or  apoplexy, 
supervene.  Such  attacks  may  come  on  at  any  time  during  the 
initial  period.  After  a  few  premonitory  symptoms,  such  as 
restlessness,  excitement,  and  sleeplessness,  the  pktient  suffers 
from  a  sudden  loss  of  consciousness.  Quite  frequently  there 
is  a  loss  of  power,  usually  involving  one-half  of  the  body,  as  in 
an  ordinary  apoplectic  stroke.  Usually  this  hemiplegia  is 
temporary,  and,  often,  to  the  surprise  of  the  physician  who  has 
been  called  in  and  who  is  not  familiar  with  the  previous  condi- 
tion of  the  patient,  disappears  in  a  few  hours;  only  infrequently 
does  it  last  a  day  or  two.  Sometimes  both  sides  of  the  body 
are  involved,  but  the  paralysis  usually  predominates  upon  one 
side.  Less  frequently  than  apoplectiform  attacks  are  seizures 
in  which  the  unconsciousness  is  attended  by  a  convulsion,  as  in 
epilepsy.  The  resemblance  to  an  ordinary  attack  of  epilepsy 
may  be  very  close,  save  that  the  convulsion  may  be  longer 
sustained  and  the  recovery  of  consciousness  much  slower. 
Sometimes  a  Jacksonian  epilepsy  is  closely  simulated,  the  con- 
vulsion being  confined  to  one  extremity,  usually  an  arm. 
Sometimes  a  paralysis  or  weakness  of  variable  duration  follows 
such  a  seizure;  at  other  times,  again,  no  noticeable  change  of 
power  is  subsequently  observed.  In  the  epileptiform  attack 
consciousness  may  not  be  completely  lost,  rarely  it  is  preserved; 
in  the  apoplectiform  attack  the  loss  is  quite  complete.  It 
should  be  added  that,  on  the  whole,  apoplectiform  seizures 
are  more  frequent  in  the  initial  period  of  paresis  than  epilepti- 
form. However,  epileptiform  attacks,  as  here  described, 
may  not  only  occur  during  the  initial  period,  but  may  be  the 
first  crass  sign  of  the  developing  disease.  When  such  an 
attack  assumes,  as  the  writer  has  seen,  a  typical  Jacksonian 
type  in  a  case  that  has  not  previously  been  under  observation. 


276  MENTAL    DISEASES 

the  situation  may  be  very  puzzling;  that  there  is  great  danger 
here  of  error  in  hasty  diagnosis  need  not  be  pointed  out. 

Seizures  are  not  present  by  any  means  in  all  cases.  In  their 
absence,  the  transition  from  the  initial  to  the  established  period 
may  be  extremely  gradual.  Again,  the  inference  must  not  be 
drawn  that  seizures  are  limited  to  the  initial  period.  As  a 
matter  of  fact,  they  may  occur  at  any  stage  of  the  disease. 
As  a  rule,  apoplectiform  attacks  occur  relatively  early,  epilepti- 
form attacks  relatively  late.  That  exceptions  to  this  rule 
obtain,  we  have  already  seen.  Finally,  as  above  indicated, 
seizures  of  any  kind  may  be  absent  throughout. 

We  may  consider  that  the  patient  has  fairly  entered  the  fully 
established  or  second  stage  of  the  disease,  when  the  physical 
signs  have  become  well  defined.  Traces  of  these  signs  are, 
as  we  have  seen,  already  present  in  the  prodromal  period. 
Now  they  are  more  pronounced.  If  we  test  the  muscular 
strength  of  the  patient,  we  find  that  it  is  markedly  diminished. 
Tremor,  distinct,  perhaps  fine,  more  frequently  coarse,  is  noted 
in  the  hands,  the  lips,  and  tongue,  and  is  elicited  or  becomes 
more  pronounced  upon  effort  or  intention.  The  patient's 
movements,  as  a  whole,  may  be  awkward,  may  lack  coordina- 
tion. Again,  they  may  be  spasmodic  and  jerky.  Most  fre- 
quently it  is  the  face  which  attracts  our  attention.  Irregularly 
recurring  t^vitches  of  the  facial  muscles,  tremulousness  of  the 
lips  or  of  the  muscles  about  the  eyes  and  forehead  are  striking 
symptoms.  The  lines  of  the  face,  as  already  noted  in  the  initial 
period,  are  less  pronounced;  this  is  especially  true  of  the  naso- 
labial fold  and  of  the  lines  about  the  forehead.  The  face  may 
seem  unusually  smooth,  or,  on  the  other  hand,  sHghtly  puffy, 
perhaps  flabby  and  coarse.  Sometimes  one-half  of  the  face 
distinctly  droops  or  is  more  frequently  disturbed  by  tremors  or 
twitchings  than  the  other.     When  the  patient  is  asked  to  show 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     277 

the  tongue,  he  may  protrude  it  by  jerky  and  irregular  move- 
ments. 

If  the  movements  of  the  arms  be  examined  they  may  reveal  a 
distinct,  though  not  usually  a  coarse,  ataxia.  If  the  patient's 
station  be  tested  by  the  Romberg  method  the  sway  is  usually 
found  to  be  slightly  increased,  sometimes  not  at  all,  and  rarely 
markedly  so.  Pronounced  increase  of  sway,  such  as  is  observed 
in  tabes  may,  however,  be  met  with  in  the  ascending  or  tabetic 
form  of  the  disease  in  which  the  early  physical  signs  may  closely 
resemble  those  of  tabes. 

The  gait  of  paresis  is  very  variable.  It  may  early  reveal 
no  pecuharities  whatever,  but,  as  the  disease  advances,  dis- 
tinct ataxia  may  be  noted,  and  this  may  gradually  become  more 
pronounced.  Infrequently,  as  in  the  tabetic  form  just  men- 
tioned, ataxia  of  gait  is  an  early  sign  and  suggests  the  diagnosis 
of  locomotor  ataxia.  In  a  large  number  of  cases,  and  in  addi- 
tion to  moderate  incoordination,  the  gait  also  presents  some 
evidences  of  spasticity.  Like  the  incoordination,  however, 
this  spasticity  in  the  average  case  is  very  moderate  in  degree. 

The  knee  jerks  are  quite  commonly  exaggerated;  however, 
they  vary  greatly;  they  may  be  diminished  or  entirely  lost. 
Quite  commonly  such  a  diminution  or  loss  is  noted  in  the  tabetic 
form.  An  ankle  clonus  is  only  infrequently  present,  and  this 
is  true  also  of  the  Babinski  sign;  when  present  they  are  usually 
in  keeping  with  other  evidences  of  spasticity.  The  tendon 
reactions  of  the  upper  extremities  reveal  nothing  characteristic. 

The  eye  symptoms  of  paresis  next  claim  our  attention. 
They  are  exceedingly  important  from  the  standpoint  of  diag- 
nosis. Quite  frequently  they  occur  very  early.  The  most  com- 
mon phenomena  are  those  which  relate  to  the  pupil,  and  here 
one  of  the  earliest  signs  is  that  of  inequality.  Differences  in 
the  size  of  the  pupils  may  occur  physiologically,  but  such  dif- 
ference is  usually  very  sKght.     If,  however,  a  difference  in  the 


278  MENTAL    DISEASES 

size  of  the  pupils  be  noted,  and  this  difference  be  associated 
with  a  sluggish  light  reaction  in  either  or  both,  the  finding  sug- 
gests paresis  in  an  incipient  stage.  Again,  if  the  inequality 
of  the  pupils  be  shifting  in  character,  present  at  one  time  and 
absent  at  another,  the  same  inference  is  indicated.  Again, 
the  pupil  in  paresis  is  not  infrequently  irregular  in  shape.  It 
may  be  oval  or  ovoid  or  its  circumference  may  be  irregular;  the 
circle  may  here  or  there  be  shghtly  flattened  as  by  a  cord,  or 
it  may  be  slightly  angled.  The  deformities  are  never  gross, 
but  when  present  are  usually  very  distinct.  They  appear  to 
be  due  to  an  irregular  innervation  of  the  iris,  and  the  symp- 
tom is  to  be  regarded  as  the  forerunner  of  the  Argyll-Rob- 
ertson pupil.  The  irregularity,  like  the  inequality,  is  usu- 
ally changing  and  shifting;  it  is  present  at  times  and  absent 
at  others ;  indeed,  the  shape  may  change  while  under  obser- 
vation, and  thus  may  justify  the  term  ameboid  pupil.  If 
inequality  and  irregularity  both  obtain,  the  inference  as  re- 
gards a  developing  paresis  is  equally  obvious.  How  significant 
these  observations  become  when  they  are  attended  by  a  dimin- 
ished or  a  sluggish  light  reaction  we  will  presently  see. 

Changes  in  the  size  of  the  pupils  are  infrequent  in  the  early 
stage  of  paresis.  Myosis  is  observed,  but  is  much  less  frequent 
than  in  tabes.  If  associated  with  a  change  of  the  light  reflex, 
it  has  of  course  special  significance.  An  unusually  large  pupil 
is  rare.  Mydriasis  does  not  occur,  if  at  all,  until  the  disease 
is  far  advanced. 

In  the  early  diagnosis  of  paresis  changes  in  the  equality, 
shape,  and  size  of  the  pupils  are  very  important,  but  the  symp- 
tom of  paramount  value  is  change  in  the  behavior  of  the  pupil 
to  light.  The  light  reflex  is  impaired  or  lost  sooner  or  later  in 
the  great  majority  of  cases.     Long  before  the  pupil  becomes 


MENTAL    DISEASE    BELATED    TO    SOMATIC    AFFECTIONS     279 

fixed  to  light,  it  is  noted  that  the  response  is  lessened  in  degree 
or  that  it  is  distinctly  sluggish  or  retarded.  A  point  of  great 
diagnostic  importance,  in  cases  in  which  the  pupils  are  equal, 
exists  when  the  pupils  react  differently  to  Hght ;  such  an  obser- 
vation always  justifies  the  inference  that  in  one  pupil  the  light 
reaction  must  be  abnormal. 

The  reaction  to  accommodation  is  preserved  in  paresis  long 
after  the  hght  reflex  is  lost.  However,  when  the  dementia  and 
deterioration  become  profound,  as  in  the  final  bed-ridden  period, 
it  also  disappears.  The  more  advanced  the  case,  the  more  hkely  is 
there  to  be  loss  of  accommodation;  the  loss  is  present  in  both 
eyes  simultaneously. 

Changes  in  the  eyeground,  with  progressive  amblyopia  and 
amaurosis,  may  be  noted.  As  compared  with  tabes  such  changes 
are  relatively  infrequent.  The  papilla  may  be  pale,  gray,  or 
white.  On  the  whole,  however,  optic  atrophy  sufficiently 
marked  to  cause  blindness  is  rare  in  paresis.  Notwithstanding, 
fundus  changes  are  exceptionally  met  mth.  among  the  first 
phj^sical  signs.  Amblyopia  is  more  commonly  observed  than 
amaurosis.  Amblyopia,  again,  may  exist  without  any  changes 
in  the  eyeground.  Indeed,  it  may  antedate  all  other  demon- 
strable changes  in  the  eyes,  either  in  the  pupils  or  eyegrounds. 
Usually  the  degree  of  amblyopia  present  under  such  circum- 
stances is  shght.  It  may  exist  with  or  without  a  diminution  of 
the  color  sense,  but  when  present  in  a  suspicious  case  it  consti- 
tutes an  invaluable  sign. 

Disturbances  of  the  \asual  fields  in  paresis  may  occur,  but 
they  are  not  common;  especially  is  this  true  of  marked  dis- 
turbances. Concentric  reduction  may  be  noted,  and,  more 
rarely,  gross  changes,  such  as  a  hemianopsia. 

Among  the  physical  signs  of  paresis,  various  palsies  of  the 
cranial  nerves  may  occur,  more  especially  of  the  third,  fourth. 


280  MENTAL    DISEASES 

and  sixth.  These  may  give  rise  variously  to  strabismus,  diplopia, 
or  ptosis.  They  may  make  their  appearance  at  the  very  be- 
ginning of  paresis  or  may  occur  during  the  period  of  the  fully 
developed  disease.  Usually  these  palsies  are  not  pronounced 
or  striking.  Most  frequently  only  a  very  sUght  degree  of  ptosis 
or  of  weakness  of  outward  or  inward  rotation  is  noted,  and,  as  a 
rule,  careful  observation  is  required  to  detect  even  these  anoma- 
lies. Quite  commonly  they  are  transitory  and  fugacious.  At 
times  slight  atactic  movements — perhaps  suggesting  nystagmus 
— are  present.  On  the  whole,  palsies  and  other  motor  disturb- 
ances are  quite  secondary  in  importance  to  the  other  eye 
symptoms  of  paresis;  they  are  relatively  infrequent  and  incon- 
stant. 

The  usual  sequence  of  the  ocular  phenomena  may  be  briefly 
summarized  as  follows:  inequaUty  of  pupils,  irregularity  of 
pupils,  impairment  of  the  light  reflex  upon  one  or  both  sides, 
with,  at  the  same  time,  preservation  of  accommodation;  later, 
as  dementia  progresses,  impairment  and  final  loss  of  accommo- 
dation, the  pupil  being  then  inert  to  all  forms  of  excitation. 
A  fully  developed  Argyll-Robertson  pupil  may  be  present  in 
the  early  period,  which  is  infrequent,  and  in  the  established 
period.  liOss  of  accommodation  may  be  added,  in  keeping  with 
the  increasing  loss  of  mind,  in  the  latter  part  of  the  estabUshed 
period  or  in  the  final  period  of  maximum  dementia. 

It  should  be  borne  in  mind  that  the  inequality  and  irregu- 
larity of  the  pupils  may  vary  considerably  from  time  to  time; 
especially  may  this  be  observed  in  the  early  stage  of  the  affec- 
tion. Very  rarely  the  light  reflex,  it  appears,  if  impaired 
and  not  entirely  lost,  may  be  re-established  during  a  period  of 
general  improvement;  e.  g.,  during  a  remission,  as  in  a  case 
reported  by  Bumke.  The  irregularity  of  the  pupil,  so  frequently 
an  early  sign,  is  to  be  looked  upon  as  the  beginning  of  the  pro- 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     281 

gressive  iridoplegia  of  which  the  Argyll-Robertson  pupil  is  the 
more  advanced  stage  and  the  inert  pupils  of  the  terminal 
period  the  final  stage.  Finally,  it  should  be  added  that,  in 
general  terms,  the  eyes  in  juvenile  paresis  present  a  symptom 
group  similar  to  that  found  in  older  subjects. 

Slight  disturbances  of  speech,  noted  in  the  initial  period, 
give  place  to  awkwardness,  thickness,  and  hesitation,  as  the 
established  period  is  reached.  It  is  noted  that  when  the  pa- 
tient attempts  to  speak  the  twitching  of  the  lips  and  of  the  facial 
muscles  increases.  The  enunciation  loses  its  precision.  Con- 
sonants are  pronounced  imperfectly,  syllables  are  slurred,  or 
there  is  a  quavering  break  between  syllables  or  between  words, 
or  syllables  may  be  haltingly  repeated.  In  other  words,  the 
enunciation  is  atactic.  Sometimes  the  patient  stops  because 
he  cannot  find  the  necessary  word,  or  the  wrong  word  is  used, 
or  the  sentence  is  broken,  unfinished,  or  is  unintelligible.  In 
part,  and  especially  earlier  in  the  case,  the  peculiarities  of  speech 
are  due  to  ataxia  and  tremor  of  the  various  structures — lips, 
tongue  and  palate — concerned  in  articulation.  Later,  as  the 
dementia  progresses,  distinct  aphasic  phenomena  and  phe- 
nomena due  to  poverty  of  thought  are  added.  It  is  not  un- 
common to  use,  in  examining  the  speech  of  paretics,  especially 
in  the  initial  or  early  established  period,  certain  words  or  phrases 
to  elicit  the  difficulty  of  enunciation;  for  instance,  it  is  found 
that  paretics  whose  speech  does  not  as  yet  betray  a  gross  defect 
may  have  difficulty  in  pronouncing  properly  words  containing 
both  the  letter  "1"  and  the  letter  ''r,"  such  as  "truly  rural," 
"artilleryman,"  and  the  like. 

The  handwriting  in  paresis  also  undergoes  a  change.  It  be- 
comes tremulous  and  irregular,  and  later  the  patient  makes 
errors  of  spelling  and  of  grammar.  Elision  of  letters,  words, 
and  syllables  occur  with  frequency,  while  the  paper  is  often 


282  MENTAL    DISEASES 

smeared  and  blotted.  A  paretic  letter  is  often  disconnected, 
betrays  the  delusions  of  the  patient;  sentences  are  incomplete; 
date  and  signature  may  be  omitted. 

The  examination  of  paretics  reveals  few  sensory  phenomena. 
Gross  anesthesias  are  rarely,  if  ever,  observed.  There  may  be 
a  blunting  or  psychic  indifference  to  cutaneous  stimulation; 
perhaps  true  hypesthesias  may  exist.  Amblyopia,  color  blind- 
ness, and  amaurosis  may,  as  we  have  seen,  be  present.  Hearing, 
smell,  and  probably  taste,  may  be  obtunded.  It  should  be  added 
that,  among  the  interesting  facts  to  be  grouped  with  the  physical 
phenomena  of  paresis,  are  first  those  of  increased  intracranial 
and  intraspinal  pressure.  This  was  demonstrated  by  Schaefer. 
Secondly,  as  we  shall  see  more  in  detail  farther  on,  the  percentage 
of  protein  in  the  cerebrospinal  fluid  is  increased,  and  the  micro- 
scopic examination,  as  in  tabes,  reveals  a  more  or  less  marked 
increase  in  the  lymphocytes. 

As  the  patient  approaches  the  established  period,  the  mental 
symptoms  of  the  initial  period  gradually  become  more  pro- 
nounced, until  they,  too,  like  the  physical  signs,  attain  a  marked 
degree  of  development.  Memory,  judgment,  uill-power,  the 
personal  habits,  now  show  great  deterioration  and  the  mental 
state  is  patent  also  to  the  lay  observor.  The  gradually  increasing 
and  progressive  dementia  may  be  the  only  form  assumed  by 
the  mental  symptoms.  However,  at  times,  other  symptoms 
are  added;  thus,  there  may  be  added  emotional  depression,  or, 
on  the  other  hand,  emotional  expansion,  and,  at  other  times 
still,  both  of  these  states  may  alternate  in  the  same  case.  As 
a  result,  paresis  may  present  itself  in  the  following  forms — first, 
the  simple  demented  form;  second,  the  depressive  form; 
third,  the  expansive  form;  and,  fourth,  the  circular  form. 

The  simple  demented  form  resembles  in  its  course  a  simple 
progressive  dementia.     It  is  often  exceedingly  gradual  in  its 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     283 

onset,  and  its  course  may  be  so  smooth  that  for  a  long  time  it 
may  remain  unrecognized.  It  appears  more  frequently  among 
women,  although  it  also  occurs  in  a  large  proportion  of  men. 
Among  women,  however,  paresis  is,  almost  as  a  rule,  less  active 
than  in  men.  Compared  with  the  depressive  and  expansive 
forms,  the  simple  demented  form  seems  to  occur  at  a  rela- 
tively early  age.  Finally,  it  is  of  longer  average  duration  than 
the  other  forms. 

The  depressive  form  of  paresis  is  characterized  by  the  fact 
that  upon  the  advent — or  perhaps  earlier — of  the  established 
period  the  patient  passes  into  a  state  of  more  or  less  marked 
mental  depression.  He  may  evolve  ideas  of  bodily  disease  or 
of  sinfulness,  or  it  may  be  of  persecution.  Occasionally 
hypochondriacal  ideas  are  manifested  by  gross  delusions;  the 
patient  may  believe  that  his  blood  has  become  congealed, 
that  his  bones  are  broken,  that  he  has  lost  his  insides,  that  his 
arms  and  his  legs  are  gone,  that  he  cannot  eat,  that  he  has  no 
mouth,  that  his  bowels  are  hopelessly  diseased,  that  he  is 
wasting  away,  that  he  is  growing  small;  or,  he  may  believe 
that  he  is  very  wicked,  that  he  cannot  be  saved,  that  there  is 
poison  in  his  food,  that  he  has  been  dead  a  thousand  years. 
The  delusions  are  multiple,  vary  constantly,  are  extremely 
shifting  and  poorly,  or  not  at  all,  systematized.  Frequently 
somatic  and  spiritual  delusions  are  intermingled.  Some- 
times attempts  at  suicide  or  at  self-mutilation  are  made, 
though,  for  obvious  reasons,  they  are  rarely  successful.  Some- 
times the  patients  become  extremely  agitated,  passing  through 
periods  or  veritable  attacks  of  fear  with  painful  confusion. 
Hallucinations  may  be  present;  the  patients  may  hear  voices, 
have  foul  tastes  and  smells.  That  the  latter  are  interwoven 
with  the  delusions  need  not  be  pointed  out.  On  the  whole,  how- 
ever, hallucinations  are  not  prominent,  and,  indeed,  they  do  not 


284  MENTAL    DISEASES 

appear  to  play  an  important  role  in  paresis  at  any  time.  It 
should  be  added  that  a  large  proportion  of  the  cases  of  the 
depressive  form  of  paresis  are  found  among  women.  Its 
average  duration  appears  to  be  less  than  that  of  the  simple 
demented  form  and  greater  than  that  of  the  expansive  form. 

The  expansive  form  of  paresis  is  characterized  by  an  ex- 
pansive mental  state.  The  tendency  to  boastfulness  and  ex- 
aggeration, noted  perhaps  in  the  initial  period,  now  becomes 
very  marked.  Delusions  extravagant  in  character  make 
their  appearance.  The  patient  believes  himself  to  be  the 
possessor  of  various  qualities  indicative  of  importance.  He 
has  an  exaggerated  feeling  of  well-being,  was  never  better 
in  his  life,  is  wonderfully  strong,  very  powerful,  very  rich.  If 
the  patient  be  a  woman,  she  is  endowed  with  great  personal 
beauty,  blessed  with  an  extraordinary  number  of  children, 
or  is  favored  by  more  than  the  usual  number  of  lovers  and 
husbands.  It  is  characteristic  of  these  delusions  of  grandeur 
that  they  are  poorly  systematized,  are  very  variable,  and  feebly 
held.  The  patient  makes  no  effort  to  account  for  his  phenom- 
enal wealth ;  to-morrow  he  may  tell  us  that  it  is  the  result  of  a 
great  invention,  or,  upon  another  day,  that  he  received  it  as  a 
bequest.  To-day  he  is  worth  two  hundred  thousand,  to- 
morrow it  may  be  many  millions,  or  the  day  following  he  has 
forgotten  about  his  wealth  and  tells  us  that  he  is  a  senator, 
a  governor,  that  he  is  a  graduate  of  Harvard,  Berlin,  or  Paris, 
that  he  is  a  great  lawyer,  or  that  he  is  an  "elegant"  singer 
and  player. 

Occasionally  the  exaltation  increases  to  such  an  extent  that 
the  excitement  resembles  that  of  mania.  The  patient  may 
become  extremely  noisy  and  pour  out  in  a  frenzy  his  ideas  of 
greatness,  of  riches,  of  owning  the  biggest  ship  on  earth,  of 
marrying  the  queen,  of  being  everything  and  everybody  that  is 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     285 

powerful  and  great.  Sometimes  he  becomes  destructive,  foul, 
and  indecent.  Periods  of  great  excitement  are  often  followed, 
like  epileptiform  or  apoplectiform  attacks,  by  a  marked  accentu- 
ation of  the  dementia. 

The  expansive  form  is,  on  the  whole,  the  least  common  form 
of  paresis.  It  occurs  more  frequently  among  men  than  among 
women.  Its  duration  is  shorter  than  that  of  either  of  the  other 
forms. 

The  circular  form  of  paresis  is  very  rare.  However,  every 
now  and  then  a  patient  who  has  been  suffering  from  a  depressive 
period  becomes  expansive.  Occasionally,  though  rarely,  a 
series  of  depressive  and  expansive  phases  may  succeed  each 
other;  usually  the  phases  are  very  short  in  duration,  some- 
times only  a  few  days.  In  one  case  observed  by  the  writer 
the  patient  was  for  a  time  depressive  and  expansive  on  alternate 
days.  Pickett  has  described  a  ease  in  which  an  expansive  phase 
of  several  months'  duration  was  succeeded  by  a  persistent 
depressive  phase.  Such  an  occurrence,  however,  appears  to  be 
exceedingly  rare. 

The  third  or  terminal  period  is  characterized  by  a  profound 
dementia.  Little  by  little,  the  various  physical  and  mental 
symptoms  of  the  second  stage  become  more  pronounced.  Con- 
versation becomes  more  and  more  difficult,  owing  not  only  to 
the  anomaUes  of  speech,  but  also  and  especially  to  the  increas- 
ing dementia.  The  voice  sounds  hollow,  rough,  or  it  may  be 
indistinct  and  weak,  because  of  the  involvement  of  the  muscles 
of  the  larynx  and  of  the  chest  walls.  Toward  the  close  of  the 
estabhshed  period  the  delusions  of  depression  or  expansion,  if 
they  have  been  present,  gradually  vanish  or  recur  only  in  oc- 
casional fragments.  Finally,  they  are  lost  altogether.  In 
numerous  ways  the  patient  shows  that  his  appreciation  of  his 
surroundings  is  more  imperfect  than  ever.     If  he  walks  at  all 


286  MENTAL    DISEASES 

he  stumbles  and  staggers  from  weakness  and  ataxia.  If  he 
sits  in  a  chair,  he  lolls  fonvard  or  to  one  side.  He  fails  to  evacu- 
ate his  bowels  and  bladder,  the  latter  are  emptied  spontaneously, 
and  he  becomes  extremely  filthy.  His  face  is  coarse  and  flabby 
and  its  expression  vacuous.  Occasionally  tremors  or  twitch- 
ings  distort  his  features,  but  they  correspond  to  no  emotion 
of  the  patient.  The  pupils  are  frequently  dilated,  usually 
unequally  so,  and  commonly  immobile.  Finally,  the  patient 
becomes  hopelessly  bedridden.  Voluntary  movements  are 
either  not  attempted  or  take  place  without  evident  purpose. 
The  extremities,  especially  in  the  non-ataxic  form,  become  more 
or  less  rigid;  in  many  cases  severe  contractures  of  both  arms 
and  legs  make  their  appearance.  The  legs  may  become  ad- 
ducted  or  firmly  crossed,  or  flexed  over  the  abdomen,  while 
the  arms  are  flexed  and  drawTi  over  the  chest.  Bed-sores, 
if  not  present  before,  make  their  appearance.  Other  profound 
trophic  changes — blebs,  boils,  hematomata,  herpetic  eruptions — 
are  the  rule.  Swallowing  becomes  increasingly  difficult.  The 
mental  faculties  are  completely,  or  almost  completely,  lost, 
and  the  existence  of  the  patient  becomes  purely  vegetative. 
Diarrhea,  cystitis,  disease  of  the  kidneys,  terminate  the  picture, 
or,  it  may  be,  tuberculosis  or  some  other  intercurrent  infection, 
such  as  influenza  or  pneumonia;  perhaps  it  is  heart  failur'fe  and 
edema  of  the  lungs  that  conclude  the  scene. 

The  physical  signs  of  paresis  are  of  course  the  same,  no  mat- 
ter whether  the  patient  suffers  from  the  simple,  the  depressive, 
or  the  expansive  form.  These  physical  signs,  as  far  as  they 
relate  to  the  nervous  system,  have  already  been  considered. 
It  remains  to  briefly  summarize  the  visceral  sjonptoms;  these, 
while  not  of  prime  importance,  merit  a  brief  consideration. 

The  circulation  in  the  larger  number  of  cases,  and  especially 
in  the  earlier  stages,  presents  an  increased  arterial  tension. 


MENTAL   DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     287 

The  second  sound  of  the  heart  is  accentuated;  the  pulse-rate 
is  slightly  increased,  rarely  slow,  and  sometimes  normal. - 

The  respiration  presents  no  special  change.  In  bedridden 
cases,  however,  the  rhythm  may  be  disturbed;  sometimes  a 
Cheyne-Stokes  respiration  is  simulated. 

Digestion  is,  as  a  rule,  well  preserved.  Late  in  the  case, 
however,  owing  to  imperfect  mastication,  the  swallowing  of  the 
food  in  bulk,  and  doubtless  also  due  to  the  defective  innerva- 
tion of  the  intestinal  tract,  diarrheas  make  their  appearance. 
Mucous  colitis,  ulceration  of  the  bowel,  and  occasional  bleeding 
or  hemorrhage  may  be  observed. 

The  urine  only  infrequently  presents  albumin.  Sugar  is 
found  rarely.  Early  in  the  case  the  urea  and  chlorids  are  in- 
creased in  amount;  later  they  are  diminished.  The  phosphates, 
urates,  and  other  solids  undergo  diminution  as  the  last  stages 
of  the  disease  are  reached. 

The  perspiration  is,  as  a  rule,  not  much  modified.  Some- 
times, however,  the  skin  is  unusually  dry  or  unusually  moist; 
occasionally  excessive  local  sweating  is  observed;  for  instance, 
over  one-half  of  the  chest  or  back  or  one-half  of  the  trunk  and 
body  generally.  In  the  late  stages  the  skin  may  become 
sticky  and  greasy.  Sometimes  it  becomes  darker,  especially 
about  the  forehead  and  temples. 

The  saliva  undergoes  no  special  change.  The  drooling  ob- 
served in  advanced  cases  is  not  necessarily  connected  with  an 
increased  secretion. 

Other  things  equal,  the  patient  loses  in  weight  during  the 
initial  period  and  during  times  of  expansion  and  excitement. 
Later  on,  however,  as  he  becomes  less  active,  he  increases  in 
weight  and  accumulates  a  soft  and  flabby  fat.  As  the  terminal 
period  is  approached,  and  thence  onward,  a  progressive  loss  of 
weight  again  occurs.     The  histologic  examination  of  the  blood 


288  MENTAL    DISEASES 

reveals  nothing  characteristic.  There  may  be  a  moderate 
degree  of  leukocj-tosis  with  some  reduction  of  the  hemoglobin. 

The  temperature  in  paresis  remains,  with  few  exceptions, 
normal.  Slight  fluctuations  may,  however,  be  noted.  A  rise 
of  temperature  generally  occurs  at  the  time  of  and  following  a 
convulsive  or  apoplectiform  attack  or  a  period  of  agitation  and 
excitement.  Rise  of  temperature,  especially  a  decided  rise,  oc- 
curring at  other  times,  must  find  its  explanation  in  some  visceral 
or  local  complication. 

Finally,  various  trophic  disturbances  occur  in  paretics. 
Among  these  we  note,  first,  simple  vasomotor  disturbances, 
such  as  local  flushing,  cyanosis,  marked  dermograph}',  per- 
sistent erj-thema,  and  slight  swellings  after  insignificant  pres- 
sure or  traumata.  The  skin  bruises  very  easity,  and  under 
these  circumstances  bed-sores  form  with  great  readiness. 
Naturally  they  occur  most  frequently  in  the  latter  part  of 
the  second  and  in  the  terminal  periods  of  the  disease.  They 
are  doubtless,  in  the  great  majority  of  cases,  due  to  pres- 
sure upon  tissue  in  a  state  of  greatly  lowered  nutrition. 
That  trophic  influences,  however,  play  an  important  role 
in  some  cases  is  suggested  by  the  rapidity  and  suddenness 
with  which  they  every  now  and  then  appear.  Besides,  there 
are  other  evidences  of  trophic  changes  furnished  by  the  skin, 
such  as  blebs,  herpetic  eruptions,  and  ulcers.  In  this  connec- 
tion, we  should  mention  especially  the  perforating  ulcer  now 
and  then  seen  on  the  ball  of  the  foot,  and  which  is  identical  in 
character  with  the  perforating  ulcer  met  with  in  tabes. 

Due  to  the  greatly  lessened  resistance  of  the  tissues,  sub- 
cutaneous and  other  ecchymoses  are  often  met  with.  Some- 
times punctifomi  hemorrhages  and  at  other  times  purpuric  spots 
and  blotches  are  present.  Sometimes,  indeed,  the  extravasa- 
tion is  very  marked  and  is  accompanied  by  a  certain  amount 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS      289 

of  swelling,  as,  for  example,  about  the  ankles,  knees,  popliteal 
spaces,  and  elbows.  The  mucous  membranes  also  present 
evidences  of  a  weakened  vasomotor  condition,  especially  in  the 
later  stages,  and  we  may  observe  epistaxis,  hematemesis,  hem- 
orrhage from  the  bowels,  and  metrorrhagia.  At  times,  also, 
blood  is  noted  in  the  urine.  In  the  terminal  stages,  also, 
hemorrhagic  extravasation  may  occur  on  the  surface  of  the 
pleura  or  into  the  substance  of  the  lung.  It  would  appear  that 
similar  occurrences  may  take  place  on  other  serous  surfaces 
and  into  other  organs.  That  they  occur  in  the  subdural  space 
is  frequently  shown  at  autopsy,  when  they  constitute  a  so- 
called  pachjTneningitis  hajmorrhagica. 

Among  the  most  interesting  trophic,  or  angioparalytic  phe- 
nomena met  with,  is  hematoma  of  the  ear.  Here  extravasa- 
tion of  blood  takes  place  into  the  fibrous  tissue  and  skin  of  the 
auricle;  sometimes  it  is  very  extensive.  Subsequently  re- 
absorption  takes  place,  followed  by  more  or  less  deformity  of 
the  ear.  Similar  hematomata  now  and  then  involve  the  nose. 
In  paretics  the  muscles  also  bruise  very  easily,  and  they  also 
may  be  the  seat  of  hematomata.  Independently  of  these, 
other  changes  may  be  noted  in  the  muscles;  thus,  there  may  be 
general  muscular  wasting;  at  times,  though  rarely,  true  mus- 
cular atrophy,  due  to  lesions  of  the  cord,  may  occur. 

The  bones  also  may  be  the  seat  of  trophic  changes.  The 
ribs  and  long  bones  generally,  frequently  become  very  brittle, 
so  that  slight  falls  or  blows  result  in  fractures.  Trophic  changes 
in  the  joints  are  also  occasionally  met  \s-ith;  the  sjTiiptoms  are 
typically  those  of  the  Charcot  joint.  There  is  exudation  of 
fluid  into  the  capsule,  erosion  of  the  cartilage,  and  destruction 
of  bone,  the  change  being  entirelj^  without  pain;  the  condition 
is  identical  vrith  the  arthropathies  met  with  in  tabes,  and,  hke 
the  latter,  doubtless  dependent  upon  changes  within  the  spinal 

19 


290  MENTAL    DISEASES 

cord.  As  might  be  expected,  they  are  more  frequent  in  paresis 
of  the  ascending  or  tabetic  form,  the  so-called  tabo-paresis. 
Charcot  joints  are  not  common  in  paresis,  but  are  met  with  in 
a  not  insignificant  percentage  of  cases. 

The  tendency  of  late  years,  following  the  teaching  of  von 
Gudden,  has  been  to  ascribe  the  so-called  trophic  phenomena 
of  paresis,  more  particularly  the  surface  changes  and  hema- 
tomata,  exclusively  to  trauma.  A  moment's  reflection  will, 
however,  convince  us  that,  if  lying  upon  the  ear  is  sufficient 
to  produce  an  othematoma,  the  nerves,  vessels  and  tissues 
generally  must  be  diseased;  similarly,  if  tripping  over  a  rug  or 
turning  in  bed  is  sufficient  to  break  a  thigh  bone,  it  is  a  fair 
inference  that  the  bone  has  undergone  a  trophic  change. 
Doubtless  the  truth  lies  midway,  for  normal  occurrences, 
every-day  traumata,  are  insufficient  to  produce  such  results 
in  a  state  of  health.  Finally,  trophic  changes,  so-called,  are 
practically  limited  to  the  advanced  stages  of  the  disease,  when 
not  only  the  nerve-centers  but  the  tissues  generally  have 
deteriorated. 

Duration,  Rate  of  Progress,  Remissions. — The  duration  of 
the  initial  period  of  paresis  cannot,  for  obvious  reasons,  be 
definitely  fixed.  It  averages  somewhere  between  one  and  three 
years;  in  the  tabetic  form  it  may  be  much  longer.  As  already 
indicated,  the  course  of  the  invasion  is  usually  slow  and  insidi- 
ous. A  patient  who  betrays  suggestive  symptoms  in  the  even- 
ing may,  to  all  intents,  be  normal  the  next  morning.  Again, 
the  invasion  may  be  irregular;  thus,  the  symptoms  having 
begun,  perhaps  faintly,  may  recede,  and  the  patient  be  appar- 
ently well  for  weeks  or  even  months,  when  they  may  again 
appear.  It  may,  therefore,  in  practice  be  impossible  to  fix 
upon  the  beginning  of  the  disease. 

The  tendency  to  the  remission  of  symptoms  may  be  evident 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     291 

not  only  in  the  initial  period,  but  also  in  the  established  period 
of  the  disease.  As  a  matter  of  fact,  there  are  very  few  cases 
in  which  remissions  do  not  at  some  time  or  other  occur,  and  in  a 
greater  or  less  degree.  At  the  time  of  a  remission,  the  patient 
is  in  an  improved  condition.  His  delusions  disappear,  his 
memory  is  better,  and  he  is  again  in  closer  touch  with  his  sur- 
roundings and  with  his  affairs.  Sometimes  the  change  is  so 
great  that  the  friends  believe  that  he  is  well,  and  that  the  phy- 
sician has  made  an  error  of  diagnosis.  On  examining  the  pa- 
tient, however,  various  symptoms  are  observed  which  show 
that,  though  improved,  he  has  not  made  a  recovery.  A  feeling 
of  well-being,  an  unwillingness  or  inability  to  realize  that  he 
has  been  ill,  a  tendency  to  plan  a  little  too  extensively  and  en- 
thusiastically for  the  future^  an  intolerance  of  further  care 
or  medical  advice,  are,  to  say  the  least,  suspicious  symptoms. 
Further,  if  the  remission  occurs  in  the  established  period  the 
physical  signs  persist.  Tremor  and  speech  difficulties  are 
lessened,  but  still  in  evidence,  and  so  it  is  with  changes  in  the 
tendon  reactions  and  the  pupils.  Every  now  and  then,  how- 
ever, if  a  remission  occurs  in  the  initial  period,  or  before  the 
established  period  has  been  fully  entered,  the  degree  of  im- 
provement is  remarkable;  indeed,  the  recession  of  mental 
symptoms  may,  for  the  time  being,  be  complete  or  nearly  so. 
.Under  such  circumstances  the  patient  may  resume  his  daily 
avocation — clerkship,  draughting,  professional  work,  and  the 
like — for  a  time.  Further,  remissions  not  only  vary  greatly 
in  degree,  but  also  in  duration;  sometimes  the  patient  shows 
his  improvement  for  a  few  days  or  a  few  weeks  only,  at  others 
for  months  and  even  years.  Remissions  of  three  or  four 
months'  duration  are  quite  common,  remissions  of  a  year  some- 
what less  so,  and  those  of  several  years  quite  exceptional. 
Well-marked  remissions  occur,  on  the  whole,  more  frequently 


292  MENTAL    DISEASES 

in  the  expansive  form  and  somewhat  more  frequently  among 
men  than  among  women.  It  should  also  be  added  that,  in 
rare  instances,  a  remission  follows  some  acute  illness,  especially 
if  the  latter  be  one  confining  the  patient  to  bed;  among  these 
may  be  mentioned  erysipelas,  trauma,  fracture,  or  abscess. 
Finally,  remissions  are  relatively  frequent  in  the  initial  period 
and  early  part  of  the  established  period.  They  are  infrequent 
when  the  second  period  is  well  established  and  do  not  occur  at 
all  in  the  third  period. 

The  remission,  as  has  already  been  indicated,  is  a  time  of 
shorter  or  longer  improvement,  but  always  temporary'.  Sooner 
or  later,  the  sjTiiptoms  reappear  and  usually  in  an  increased 
degree,  and  quite  frequently  the  affection  subsequently  pursues 
a  more  rapid  course.  Because  of  the  temporary  character  of  a 
remission,  the  patient  should,  if  possible,  be  kept  under  some 
degree  of  observation  even  when  he  seems  most  well. 

As  the  reader  is  by  this  time  aware,  a  number  of  factors  in- 
fluence the  duration  of  paresis.  Among  these,  as  already  in- 
dicated, is  the  form  which  the  disease  assumes.  It  is  longest 
in  the  simple  demented  form,  somewhat  shorter  in  the  depres- 
sive form,  and  shortest  of  all  in  the  expansive  form.  Second, 
all  factors  of  a  disturbing  character,  such  as  apoplectiform  and 
epileptiform  seizures,  or  the  occurrrence  of  periods  of  marked 
excitement  and  agitation,  greatly  hasten  the  course  of  the 
disease.  Third,  all  factors  that  tend  to  quiet  the  patient, 
such  as  sanitarium  or  asylum  life,  care  and  nursing,  tend  to 
prolong  its  course.  Fourth,  prognosis  as  to  duration  is  greatly 
influenced  by  the  occurrence  of  remissions.  Finally,  the  dura- 
tion of  paresis  is,  on  the  average,  greater  in  women  than  in 
men. 

The  average  duration  of  all  cases  is  between  two  and  three 
years.     Cases  are  occasionally',  though  infrequently,  met  with 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     293 

in  which  the  disease  pursues  a  furibund  course,  the  patient 
dying  at  the  end  of  a  few  months;  here,  it  need  hardly  be  added, 
the  actual  duration,  because  of  the  uncertainties  of  the  initial 
period,  may  be  much  greater  than  at  first  appears.  Sometimes, 
again,  the  duration  is  exceedingly  great.  This  is  not  unusual 
in  cases  which  begin  with  spinal  symptoms  and  in  which  the 
mental  symptoms  appear  relatively  late.  Paresis,  too,  of  the 
ordinary  form  every  now  and  then  presents  a  history  of  unusual 
duration.  Ten,  fifteen,  and  even  more  years  have  been  re- 
ported; it  should  be  added,  that  cases  of  such  anomalous 
length  are  usually  open  to  question. 

Prognosis. — It  has  for  many  years  been  held  that  the  prog- 
nosis as  regards  life  is  uniformly  unfavorable  and  that  to  this  rule 
there  is  no  exception.  Certain  it  is  that  this  is  invariably  true 
of  cases  in  which  no  treatment  has  been  instituted;  equally  true 
is  it  of  all  cases  treated  by  the  older  methods  of  mercurials  and 
iodids.  Whether  the  introduction  of  salvarsan  has  brought 
about  a  change  remains  to  be  seen.  There  are  some  alienists  who 
beheve  that  salvarsan  therapy  in  some  cases  arrests  the  prog- 
nosis of  the  disease,  and  also  that  a  larger  number  of  remissions 
are  observed  under  its  use.  To  the  consideration  of  this  inter- 
esting and  important  subject  we  will  return  in  the  section  on 
Treatment.  Suffice  it  to  say  here  that  in  the  observation  of  the 
writer,  paresis  is  still  one  of  the  most  fatal,  if  not  the  most  fatal, 
of  all  diseases. 

Death  may  also  occur  in  paresis  from  some  intercurrent  af- 
fection. Particularly  is  this  liable  to  happen  during  the  second 
period.  An  influenza,  a  pneumonia,  a  gastro-intestinal  attack, 
may  cut  short  the  disease.  Death  now  and  then,  also,  ensues 
during  or  follows  an  apoplectiform  or  an  epileptiform  seizure.  A 
given  number  of  paretics  thus  die  before  the  third  period  is 
reached. 


294  MENTAL    DISEASES 

Pathology. — In  order  that  we  should  entertain  clear  concep- 
tions as  to  the  nature  of  the  pathological  processes  at  work,  it 
is  necessary  that  we  should  first  consider,  though  briefly,  the 
subject  of  syphilis  of  the  nervous  system  as  a  whole.  Secondly 
it  will  be  necessary  to  re\'iew  many  facts  clinical  in  their  nature 
but  which  have  a  profound  pathological  significance.  With 
the  discover}^  of  Noguchi  of  the  actual  presence  of  the  spirochete 
in  the  paretic  brain,  the  thought  naturally  suggests  itself  that 
the  distinction  formerly  made  between  syphilis  of  the  vessels 
and  membranes  and  paraSyphilis,  i.  e.,  paresis  and  tabes,  can 
no  longer  be  maintained.  However,  while  all  diseases  of  the 
nervous  system  resulting  from  the  infection  of  the  spirochete 
fall  properly  under  the  caption  of  syphilis,  it  does  not  follow  that 
all  nervous  syphilis  is  the  same,  nor  does  it  follow  that  the 
clinical  distinctions  previously  established  can  be  abandoned. 
Syphilis  of  the  vessels  and  membranes  of  the  brain  and  cord,  i.  e., 
gummatous  infiltration  of  the  vessels  and  membranes  or  syphilis 
of  the  exudative  form  as  it  may  also  be  called,  presents,  other 
things  equal,  special  symptom  groups  with  special  possibilities 
and  probabilities  in  prognosis.  These  sjTnptom  groups,  which  are 
the  outcome  of  the  interference  of  nutrition  caused  by  a  dimin- 
ished lumen  or  occlusion  of  the  vessels  and  to  a  less  extent  of 
pressure,  it  would  be  out  of  place  to  rehearse  here;  suffice  it  to 
say  that  in  exudative  syphilis  of  the  brain  the  picture  is  that  of 
headache,  somnolence,  possibly  optic  neuritis;  or,  it  may  be  of 
palsies  of  cranial  nerves  with  or  without  hemiplegia  crossed  or 
ipsolateral,  while  mental  symptoms  are  absent  or  practically  so. 
Again,  in  exudative  syphilis  of  the  cord  the  picture  is  that  of  a 
paraplegia  in  which  spasticity  and  to  a  less  extent  ataxia  are 
the  dominant  features.  At  the  same  time  there  are  slight 
sensory  losses — not  the  retardation  of  tabes — merely  a  hypes- 
thesia.    Further,  both  the  motor  and  sensory  phenomena  are 


MENTAL   DISEASE   RELATED    TO    SOMATIC   AFFECTIONS      295 

miequally  marked  in  the  two  extremities,  one  limb  is  always 
more  affected  than  the  other.  There  is  also  a  history  of  a 
transient  bladder  disturbance;  first  delayed  micturition,  then 
slightly  lessened  vesical  control,  and  lastly  and  quite  com- 
monly spontaneous  disappearance  of  the  sphincter  symptoms. 
Finally,  there  is  a  conspicuous  absence  of  hghtning-Hke,  shoot- 
ing, or  other  pains.  The  picture  is  due  primarily  to  gununatous 
infiltration  of  the  vessels  and  membranes  of  the  cord.  CHn- 
ical  observation  has  not  only  enabled  us  to  make  broad  and 
fundamental  distinctions  between  these  cardinal  symptom 
groups,  but  it  has  also  taught  a  significant  lesson  as  regards 
the  chnical  histories  of  the  patients.  Thus,  every  physi- 
cian of  experience  knows  that  in  parasyphilis  the  history  of  the 
original  infection,  i.  e.,  of  the  primary  lesion,  is  often  difficult 
to  elicit,  often  denied,  and  often  uncertain.  Particularly  is  this 
true  of  paresis;  it  is  almost  equally  true  of  tabes,  while  it  is  quite 
the  exception  in  exudative  cerebral  and  spinal  syphiHs.  In  keep- 
ing with  this  a  search  upon  the  genitals  for  scars  of  the  initial 
lesion  is  almost  invariably  met  by  failure  in  both  paresis  and 
tabes.  Again,  a  history  of  secondary  symptoms,  eruptions,  mu- 
cous patches,  sore  throat,  and  falling  out  of  hair  is  commonly 
wanting  in  paresis  and  tabes;  if  the  writer  were  to  trust  his  own 
experience  entirely,  he  would  say  invariably  wanting.  It  is  this 
fact  which  has  led  physicians  at  times  to  speak  of  paresis  and 
tabes  as  the  outcome  of  "mild  syphilis,"  a  designation  which  is 
singularly  inapt  when  apphed  to  affections  which  are  attended 
by  gross  and  permanent  destructive  changes. 

How  greatly  exudative  syphilis  of  the  brain  and  cord  differ 
in  their  sjmiptomatology  from  that  of  paresis  and  of  tabes  need 
hardly  be  pointed  out.  Paresis,  in  brief,  presents  the  picture  as 
already  described,  of  a  gradually  oncoming  and  slowly  increasing 
dementia.    Certain  physical  signs,  as  we  have  seen,  are  present. 


296  MENTAL    DISEASES 

and  these  not  only  differ  largely  in  kind  from  those  of  exudative 
syphilis  of  the  membranes  and  vessels  but  also  in  being  less 
clearly  marked  and  definite.  There  are  present  a  variable 
intention  tremor  of  hands,  lips,  and  tongue,  an  atactic  speech, 
inequalities,  irregularities,  sluggishness  or  fixation  of  pupils, 
the  Argyll  Robertson  pupil,  slight  modifications  of  gait,  tran- 
sient apoplexies  or  hemiplegias,  and  infrequently  transient, 
slightly  marked  fugacious  pareses  of  the  cranial  nerves,  and  other 
symptoms  all  of  them  the  outcome  of  a  general,  a  parenchy- 
matous, destruction  of  brain  tissue. 

In  tabes  the  symptom  group  also  differs  widely  from  that  of 
gummatous  disease  of  the  vessels  and  membranes  of  the  cord. 
The  lightning-like  pains,  the  loss  of  reflexes,  the  incoordination, 
and  the  Ai-gyll-Robertson  pupil  form  a  well-defined  and  dis- 
tinctive clinical  picture.  This  peculiar  clinical  history  suggests 
a  possible,  if  not  a  probable,  difference  in  the  character  of  the 
infection.  It  is  difficult,  on  the  other  grounds,  to  interpret  the 
cases  in  which  both  husband  and  wife  suffer  from  paresis  or  in 
which  both  suffer  from  tabes.  It  is  quite  startling  to  realize 
that  one  of  the  conjugal  partners  does  not  suffer  from  exudative 
syphilis  of  the  membranes  and  vessels  and  the  other  from  paresis, 
but  that  both  suffer  from  paresis.  Morel-Lavallee  and  Belieres 
have  reported  an  instance  in  which  five  men  infected  by  the  same 
woman  all  became  paretic,  and  to  this  number  Ramadier  added 
a  sixth,  likewise  paretic  from  the  same  source.  Brosius  has  re- 
ported an  instance  of  seven  glassblowers  all  infected  by  the 
same  mouthpiece,  of  whom  five  were  attacked  either  by  tabes 
or  paresis,  while  the  remaining  two  presented  very  suspicious 
symptoms.  Similar  instances  have  been  recorded  by  Nonne, 
by  Marie  and  Bernhard,  and  by  Erb.  Certainly  it  would  seem 
that  at  times  the  germs  of  syphilis  undergo  some  change, 
acquire  some  quality  which  especially  favors  the  development 


MENTAL   DISEASE    RELATED    TO    SOIVL4.TIC    AFFECTIONS     297 

of  paresis,  or  it  may  be  that,  as  Mott  has  suggested,  "there  may 
be  varieties  of  spirochetes  as  there  are  different  varieties  of 
trypanosomes,  the  morphological  character  of  which  would  not 
permit  of  differentiation."  To  the  writer  the  clinical  evidence 
points  strongly  to  the  existence  of  a  special  strain  of  spirochete 
as  the  cause  of  paresis. 

Whatever  the  facts  as  to  the  character  of  the  spirochete  of 
paresis  may  be,  the  germ  is  found  deeply  placed  in  the  brain 
substance,  predominating,  as  might  be  expected,  in  the  cortical 
tissue.  Here  it  appears  to  give  rise  to  toxins,  and  the  latter, 
in  turn,  to  antitoxins. 

It  is  extremely  probable  that  the  very  earliest  sj^mptoms  of 
paresis  are  not  the  result  of  organic  change,  but  of  a  toxic 
condition.  At  least  this  inference  is  justifiable  in  all  cases 
except  perhaps  those  of  the  ascending  or  spinal  form.  The 
mere  fact  that  in  the  initial  period  there  may  be  a  complete 
recession  of  symptoms  indicates  that  the  change  in  the  nerve- 
centers  is  as  yet  functional;  i.  e.,  is  such  a  change  as  might 
accompany  the  varying  action  of  toxic  agents.  That,  indeed, 
in  the  very  early  period  structural  changes  are  absent  is  proved 
by  autopsies  in  cases  which  have  died  at  this  period  from 
intercurrent  disease  or  accident;  in  cases  djdng  during  the 
initial  period  in  which  organic  changes  do  exist,  the  latter  are 
frequently  found  to  be  sHght  and  inconsequential.  When 
physical  signs  have  made  their  appearance  it  is,  of  course, 
proper  to  infer  that  they  are  due  to  organic  changes.  Again, 
the  added  mental  phenomena  which  in  one  group  of  cases 
manifest  themselves  by  depression,  and  in  another  by  expansion, 
also  point  to  a  toxic  condition.  It  is  the  actual  mental  loss, 
the  quantitative  reduction  of  mind,  which  indicates  an  organic 
change,  a  destruction  of  tissue. 

Autopsies  in  cases  dying  during  the  established  period  and 


298  MENTAL   DISEASES 

in  the  terminal  period  reveal  striking  and  quite  constant  find- 
ings. Naturally,  they  reach  their  greatest  development  in  cases 
dying  in  the  terminal  period. 

It  is  noticed,  on  opening  the  skull,  that  the  calvarium  is 
much  thickened;  often  the  diploic  structure  has  been  much 
encroached  upon,  and  here  and  there  it  may  have  disappeared. 
It  is  also  observed  that  the  calvarium  is  removed  with  difficulty; 
it  is  more  or  less  adherent  to  the  dura,  often  firmly  so.  The 
dura,  too,  is  much  thickened,  and,  when  it  is  opened  and  turned 
back,  its  inner  surface  often  presents  the  condition  known  as 
pachymeningitis  hsemorrhagica.  Repeated  exudations  of  blood 
upon  its  surface  have  been  followed  by  thickening,  reddish 
deposits,  or  more  or  less  evidence  of  organization;  at  times 
cysts  are  formed,  often  small  and  again  quite  large,  adherent 
to  the  dura,  covered  by  a  thin  new-formed  membrane  and  con- 
taining clear,  or  it  may  be  yellowish  or  reddish,  fluid;  such  for- 
mations are  sometimes  spoken  of  as  arachnoid  cysts.  When 
the  skull  is  opened  it  is  also  noted  that  an  unusual  amount  of 
cerebrospinal  fluid  escapes. 

When  the  brain  is  removed  and  placed  upon  the  table,  it  is 
observed  that  it  does  not  retain  its  shape  as  well  as  does  the 
healthy  brain;  it  sags  and  flattens;  it  is  obviously  softer  than 
normal.  The  pia  arachnoid  is  opalescent  and  infiltrated; 
particularly  is  this  noted  along  the  sides  .of  the  veins.  The 
pacchionian  bodies  are  increased  in  number.  If  we  attempt 
to  remove  the  pia,  we  find  that  it  is  not  only  thickened,  but 
adherent  to  the  subjacent  cortex;  so  much  so  that,  if  we  per- 
sist in  the  attempt,  the  cortex  is  torn  off  along  with  the  pia. 
We  are  also  impressed  by  the  fact  that  the  convolutions  are 
markedly  small  and  atrophied  and  that  the  sulci  are  wide  and 
gaping.  The  meshes  of  the  pia  arachnoid  are  everywhere 
filled  with  fluid,  as  are  the  gaping  sulci.     Here  and  there  the 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     299 

cerebral  cortex  is  depressed,  as  by  loss  of  substance,  and  the 
surface  of  the  superjacent  pia  may  present  at  such  places  the 
appearance  of  covermg  a  cyst.  As  a  whole,  the  changes  in  the 
convolutions  are  more  marked  in  the  frontal  and  parietal 
regions  than  elsewhere. 

If  we  incise  the  brain,  we  find  that  the  cut  surface  is  more 
moist  than  usual,  and  here  and  there  we  see  small  vessels 
lying  loosely  in  what  are  evidently  dilated  perivascular  spaces. 
Changes  similar  to  those  noted  in  the  cortex  and  white  matter 
are  noted  in  the  basal  ganglia,  the  crura,  pons,  and  cerebellum. 
The  ventricles  are  found  dilated,  while  the  ependyma  is  rough- 
ened by  granulations;  the  last-mentioned  changes  are  particu- 
larly pronounced  in  the  fourth  ventricle.  The  endothelium 
seems  to  have  disappeared,  while  the  granulations  have  their 
origin  in  a  proliferation  of  the  neuroglia.  If  the  brain  be 
weighed,  it  is  found  to  be  much  less  heavy  than  normally; 
thus,  the  author  found  the  average  weight  of  nine  male  paretic 
brains  to  be  only  41.8  ounces,  while  the  average  weight  of  four 
female  paretic  brains  was  only  37.1  ounces.  Of  course  the 
evidences  of  atrophy  and  loss  of  substance  are,  other  things 
equal,  more  pronounced  in  patients  in  whom  life  has  been  long- 
est maintained. 

If  the  cortex  be  examined  microscopically,  it  is  found  to  be 
thinner  and  to  have  lost  some  of  its  cellular  elements;  indeed, 
it  is  frequently  impossible  to  trace  the  various  layers  of  the 
cortex.  The  nerve  cells  have  undergone  granular  and  pig- 
mentary degeneration,  atrophy,  and  loss  of  cell  processes. 
Like  the  nerve  cells,  the  nerve  fibers  have  undergone  atrophy 
and  destruction,  and  this  is  true  ahke  of  the  radiating  fibers 
which  enter  the  cortex  and  of  the  tangential  fibers  which  con- 
stitute its  outermost  layer.  Everywhere  there  are  evidences 
of  prohferation  of  the  neuroglia;    here  and  there  large,  many 


300  MENTAL    DISEASES 

branched  glia  cells  are  seen,  the  so-called  spider-cells.  The 
vessel  walls  and  the  perivascular  spaces  are  densely  infiltrated 
with  nuclei,  with  lymphocytes,  and  plasma  cells.  Elongated 
rod-like  cells  are  also  found  in  the  neighborhood  of  vessels. 
Similar  changes  are  found  in  the  basal  ganglia  and  cerebellum. 

In  the  cord,  changes  in  the  pia  are  more  or  less  evident;  those 
in  the  dura  less  frequent.  The  cord  substance  may  reveal 
degenerative  changes,  increase  of  the  neuroglia  and  connective 
tissue  elements,  and  changes  in  the  vessel  walls,  though  these 
are  rarely  as  marked  as  in  the  brain.  In  many  cases,  especially 
in  those  in  which  spasticity  and  perhaps  late  contractures  have 
been  features,  we  find  CAddences  of  descending  degeneration  in 
the  pyramidal  tracts;  in  other  cases,  again,  in  which  a  tabetic 
symptom  group  was  early  present,  we  find  changes  in  the  pos- 
terior columns.  Not  uncommonly  degenerative  changes  are 
found  in  both  lateral  and  posterior  columns  or  irregularly 
evident  in  various  portions  of  the  cord.  The  peripheral  nerves 
also  may  reveal  changes  similar  to  those  found  in  tabes. 

Diagnosis. — Our  increasing  knowledge  of  the  etiology  and 
pathology  of  paresis  has  given  rise  to  the  hope  that  perhaps 
it  may  be  possible  of  cure  or  at  least  of  being  arrested  in  its 
progress,  especially  if  it  be  recognized  sufficiently  early.  The 
early  diagnosis  of  paresis  has,  therefore,  assumed  a  great  impor- 
tance. It  is,  of  course,  the  practising  physician,  the  family  doc- 
tor, who  sees  the  patient  first,  and  it  often  depends  upon  the 
alertness  and  acumen  of  the  latter  whether  an  early  diagnosis  is 
made.  There  are  commonly  certain  suggestive  facts  associated 
with  the  manner  in  which  the  case  comes  to  the  attention  of 
the  physician  which,  other  things  equal,  should  excite  the 
suspicions  of  the  latter. 

First,  the  patient  in  the  early  stages  of  paresis  is  usually 
brought  to  the  physician  by  relatives  or  friends.    Rarely  does 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     301 

he  come  of  his  own  initiative.  Secondly,  it  is  the  relatives  or 
friends  who  detail  the  symptoms,  not  the  patient.  They  give  an 
account  of  changes  which  they  have  noted  and  of  which  the 
patient  himself  has  not  been  cognizant  or  to  which  he  has  paid 
no  attention.  The  signs  of  ill  health  are  first  observed  by  those 
about  the  patient  and  not  by  the  patient  himself.  Indeed, 
the  latter  does  not  actively  complain  unless  there  happen  to  be 
present  tabetic  or  neuralgic  pains  or  perhaps  attacks  of  head- 
ache, all  of  them  symptoms  by  no  means  frequent.  He  is 
commonly  regarded  by  his  friends  as  being  nervous  or  suffering 
from  nervous  prostration.  His  conduct,  however,  is  in  marked 
contrast  to  that  of  the  neurasthenic  patient,  who  not  only  seeks 
the  physician's  advice  himself,  but  also  has  at  his  tongue's 
end  a  long  list  of  complaints.  Again,  the  physical  appearance 
of  the  neurasthenic  betrays  no  somnolence;  his  features  lack  none 
of  their  accustomed  expression;  there  is  no  lessening  of  the  facial 
folds;  it  is  still  the  same  face  to  friends  or  relatives.  It  has  not 
become  altered  so  as  to  suggest  that  the  patient  is  a  changed 
man.  The  friends  are  never  the  ones  to  discover  that  the  patient 
is  ill,  and  indeed  quite  frequently  listen  to  his  complaints  with 
.  impatience  and  incredulity.  Finally,  when  his  case  is  studied 
by  the  physician,  it  is  found  that  he  presents  the  symptom  group 
of  ready  exhaustion  so  typical  of  neurasthenia  without  the 
slighest  change  in  mental  quality. 

The  friends  of  the  paretic  patient  tell  a  very  different  story, 
Often  they  will  maintain  that  his  appearance  and  manner  have 
changed,  that  he  no  longer  attends  to  his  business  carefully  nor 
does  his  work  as  well  as  formerly,  and  little  by  little  the  symp- 
toms already  detailed  as  characterizing  the  beginning  of  paresis 
(see  p.  271)  are  eUcited. 

Of  course  as  soon  as  physical  signs  begin  to  make  their  ap- 
pearance, the  diagnosis  is  very  readily  made,  but  at  such  time 


302  MENTAL    DISEASES 

the  transition  from  the  prodromal  to  the  established  period  is 
already  taking  place. 

Obviously  it  is  the  imperative  duty  of  the  physician,  in  every 
case  presenting  the  slighest  suspicion  of  paresis,  and  independent 
of  any  clinical  history,  to  insist  upon  a  serological  examination. 
Here  we  have  happily  a  means  of  diagnosis  of  great  value. 
Four  reactions  are  to  be  studied  ;^rsf,  the  Wassermann  reaction 
in  the  blood,  which  as  we  have  already  seen  is  positive  in  almost 
100  per  cent.;  second,  the  Wassermann  reaction  in  the  cerebro- 
spinal fluid,  which  is  positive  in  about  90  per  cent,  when  0.2  c.c. 
of  fluid  are  used,  and  in  100  when  larger  quantities  (e.  g.,  2  c.c.) 
are  used;  third,  the  globulin  test,  termed  by  Nonne  the  "Phase  I" 
reaction;  fourth,  the  presence  or  excess  of  lymphocytes  and 
other  formed  elements  in  the  cerebrospinal  fluid,  commonly 
spoken  of  as  lymphocytosis  or  pleocytosis. 

For  the  benefit  of  such  of  my  readers  who  are  not  in  touch 
with  laboratory  methods,  it  may  be  briefly  stated  that  the 
Wassermann  test  depends  upon  the  presence  of  antibodies  in 
the  serum  of  the  blood  or  in  the  spinal  fluid.  It  will  be  recalled 
that  the  body  which  results  from  the  union  of  an  antigen  and 
antibody  is  composed  of  two  basic  substances,  one  the  ambo- 
ceptor and  the  other  the  complement.  Complement  binding — 
a  reaction  which  was  discovered  by  Bordet  and  Gengou — con- 
sists in  the  fact  that  when  an  antigen  and  its  corresponding 
antibody  meet  the  complement  is  held  fast.  This  fact  can  be 
demonstrated  by  the  addition  of  a  hemolytic  system;  if  the 
complement  has  been  held  fast  there  is  no  hemolysis. 

The  third  reaction,  the  determination  of  the  presence  of  an 
excess  of  protein,  globuhn,  in  the  cerebrospinal  fluid,  depends 
upon  the  fact  that  the  cerebrospinal  fluid  normally  contains 
merely  a  trace  of  protein  substances  and  that  any  appreciable 
increase   has   a   pathological   significance.     Various   methods 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     303 

have  been  devised  for  the  performance  of  this  test,  which  it 
would  be  out  of  place  to  discuss  here.  Suffice  it  to  say  that  the 
"Phase  I"  reaction  of  Nonne  consists  in  the  addition  of  a 
saturated  ammonium  sulphate  solution  to  an  equal  quantity 
of  spinal  fluid.  If  the  fluid  becomes  turbid  three  minutes  after 
the  addition  of  the  ammonium  sulphate  solution,  the  reaction 
is  positive. 

The  fourth  reaction  depends  upon  the  fact  that  normally  the 
cerebrospinal  fluid  contains  very  few  formed  elements.  Of 
these,  the  small  lymphocytes  largely  predominate.  The  number 
estimated  as  normal  to  the  cerebrospinal  fluid  is  variously 
given  as  five  to  six  cells  at  the  most  per  c.mm.  (Fuchs-Rosen- 
thal)  or  eight  per  c.mm.  (Kaplan).  The  borderline  count  is 
placed  by  Kaplan  as  high  as  nine  to  fifteen  per  c.mm.  Under 
pathological  conditions  this  number  may  be  greatly  increased. 
Pleocytosis  is  always  indicative  of  meningeal  irritation  or  in- 
flammation. The  greater  the  increase,  the  more  active  the  patho- 
logical process.  In  both  paresis  and  tabes  the  increase  is 
usually  decided.  The  cell  counts  may  range  as  high  as  fifty 
or  sixty  cells  per  c.mm.  and  at  times  into  the  hundreds.  On  the 
other  hand,  cases  of  tabes  are  met  with  in  which  an  increase  of 
lymphocytes  is  not  present;  evidently  we  have  here  to  do  with 
very  chronic  and  inactive  cases.  Similarly  in  cases  of  paresis 
long  stationary  or  very  slow  in  course  we  may  find  counts  rang- 
ing comparatively  Httle  above  the  normal,  e.  g.,  eighteen  or 
twenty-three  per  c.mm. 

It  should  be  mentioned  that  Alzheimer  and  others  have  placed 
especial  importance  on  the  finding  of  plasma  cells  in  the  cere- 
brospinal fluid.  These  are  much  larger  than  the  lymphocytes 
with  markedly  staining  nuclei.  Their  significance  is,  however, 
doubtful;  many  cases  of  paresis,  as  Kaplan  points  out,  do  not 
contain  them. 


304  MENTAL    DISEASES 

Finally,  the  Wassermann  reaction  though  present,  as  we  have 
seen,  in  the  great  majority  of  cases,  is  occasionally  absent  both 
in  the  blood  and  in  the  cerebrospinal  fluid.  This  fact  is  in 
keeping  with  the  findings  in  tabes  in  which  the  Wassermann  re- 
action in  the  blood  may  be  absent  in  about  30  per  cent,  of 
the  cases  and  may  also  be  wanting  occasionally  in  the  cerebro- 
spinal fluid.  Obviously  the  absence  of  the  reaction  is  con- 
sonant with  a  lessened  or  arrested  activity  of  the  spirochete 
and  a  consequent  absence  of  antibody  formation.  Every  now 
and  then,  though  rarely,  the  clinical  signs  of  paresis  are  indubi- 
tably present  and  yet  we  receive  from  the  laboratory  a  negative 
serological  report.  Clearly,  such  a  condition  means  a  relative 
degree  of  quiet  and,  for  the  time  being,  of  arrest  of  progress. 
However,  in  a  suspicious  case  of  paresis,  i.  e.,  a  case  in  which 
neither  the  mental  nor  physical  signs  are  such  as  to  permit  of  an 
absolute  diagnosis,  and  in  which,  on  the  other  hand,  the  case 
obviously  cannot  be  classified  under  neurasthenia,  psychas- 
thenia,  or  other  neurosis,  we  are  left  sadly  in  the  dark.  Of  course, 
the  old  therapeutic  test  of  tolerance  to  the  iodids  and  mercurials 
may  be  tried  and,  if  successful,  may  turn  the  scale.  However, 
there  is  another  laboratory  test,  which  if  available,  may  be 
applied.  This  is  the  colloidal  gold  test.  This  test  depends 
upon  the  principle  discovered  by  Zsigmondy  that  solutions 
of  electrolytes  precipitate  colloidal  gold;  further,  that  under 
given  conditions,  e.  g.,  in  the  absence  of  electrolytes,  proteins 
will  do  the  same  thing,  and  that  in  the  presence  of  electrolytes, 
they  inhibit  precipitation.  These  facts  have  been  applied  by 
Lange  to  the  examination  of  the  spinal  fluid.  For  the  details 
the  reader  is  referred  to  special  works  upon  serology,  for  in- 
stance, that  of  Kaplan,  or  to  the  admirable  articles  of  Fordyce. 
The  test  is  performed  with  ten  dilutions  of  spinal  fluid.  The 
negative  reaction  is  indicated  by  a  salmon  red,  while  the  various 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     305 

degrees  of  precipitation  are  indicated  by  change  of  color  in 
the  tubes  from  red  to  red  blue,  lilac  or  blue,  blue,  blue  gray  or 
gray,  to  colorless.  According  to  Fordyce,  in  paresis,  precipita- 
tion of  the  colloidal  gold  occurs  regularly  in  the  first  four  to 
eight  tubes  with  decolorization  or  a  turbidity.  To  this  series 
of  changes  the  term  "paretic  curve"  has  now  come  to  be  appHed. 

Finally,  emphasis  should  once  more  be  laid  upon  the  definite 
and  positive  value  of  the  physical  signs  of  paresis.  While  the 
great  importance  of  laboratory  reports  should  not  be  under- 
estimated, the  possibility  of  error  should  not  be  lost  sight  of, 
especially  in  the  performance  of  the  Wassermann  test.  Under 
all  circumstances  the  clinical  evidence,  if  positive,  must  stand. 

Treatment. — Contrary  to  the  plan  pursued  elsewhere  in  this 
volume,  the  writer  has  thought  it  wise,  because  of  its  highly 
special  character,  to  consider  the  treatment  of  paresis  in  the 
present  section.  Since  the  introduction  of  salvarsan,  renewed 
efforts  have  been  made  to  gain  control  of  this  disease,  or,  at  least, 
to  make  a  more  or  less  durable  impression  upon  its  progress. 
While  positive  statements  as  to  the  results  achieved  do  not 
meet  with  general  acceptance,  it  is,  notwithstanding,  justifiable 
to  employ  any  means  at  our  disposal  in  an  affection  which, 
when  untreated,  is  invariably  fatal. 

The  original  employment  of  salvarsan  by  intravenous  injec- 
tions made  little  if  any  impression  upon  the  course  or  progress 
of  the  disease.  Paresis,  as  has  been  pointed  out,  is  a  parenchyma- 
tous affection,  and  one,  therefore,  in  which  remedies  which 
might  be  efficacious  in  exudative  syphilis  of  the  vessels  and 
membranes,  would  probably  have  but  little  effect.  It  was  soon 
learned  also  that  salvarsan  diffuses  little  if  at  all  into  the  cavity 
of  the  dura.  Various  attempts  were  then  made  to  apply  the 
remedy  directly  by  means  of  intradural  injections;  for  instance, 
by  Marinesco,  Robertson,  Sicard  and  Lapointe,  and  others, 

20 


306  MENTAL    DISEASES 

but  it  was  the  method  of  Swift  and  Ellis  which  finally  came 
into  vogue.  In  this  method  the  patient  receives  an  intravenous 
injection  of  salvarsan  or  neosalvarsan.  After  an  interval  of 
thirty  to  forty  minutes,  some  40  c.c.  of  blood  are  withdrawn 
from  a  vein.  Swift  and  Ellis  beUeved  that  the  blood  contains  a 
maximum  amount  of  salvarsan  at  the  end  of  an  hour;  opinions, 
however,  are  divided  and  some  physicians  wait  only  twenty 
minutes. 

The  blood  withdrawn  is  allowed  to  stand  over  night,  the  super- 
natant fluid  is  pipetted  off,  and  then  centrifuged  at  3000  revolu- 
tions for  a  period  of  half  an  hour.  The  serum  is  then  inactivated 
at  a  temperature  of  56°  C.  Ten  to  twenty  cubic  centimeters, 
diluted  with  an  equal  or  twice  the  amount  of  salt  solution,  are 
then  injected  intradurally.  Usually  the  intraspinous  injection 
is  given  about  twent\'-four  hours  after  the  intravenous.  The 
patient  either  lies  upon  his  side  or  sits  upon  the  edge  of  the  bed 
with  his  back  to  the  operator.  Before  making  the  injection, 
considerable  cerebrospinal  fluid  should  be  permitted  to  escape, 
say  some  40  c.c.  or  more.  The  rule  that  we  have  followed  in 
my  own  service  is  to  allow  the  fluid  to  escape  until  all  evidences 
of  increased  pressure  have  subsided,  and  at  times  until  60  or  70 
c.c.  have  been  drained  off.  After  giving  the  injection,  the 
patient  is  placed  upon  his  back  without  any  pillow  under  his 
head  and  the  foot  of  the  bed  elevated  some  ten  or  twelve  inches. 
This  position  is  maintained  for  some  three  hours,  after  which  the 
patient  is  allowed  to  assume  a  more  comfortable  position.  For 
reasons  which  will  become  apparent  later,  I  have  not  repeated 
this  procedure  more  often  than  once  in  ten  days  or  two  weeks, 
and  frequently  it  is  wise  to  allow  a  still  longer  interval  to  elapse. 

Ogilvie  modified  the  Swift-Ellis  method  by  mixing  the  salvar- 
san directly  with  the  blood-serum  outside  of  the  bod}'.  Forty 
or  fifty  c.c.  of  blood  are  withdrawn.     This  is  allowed  to  stand 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     307 

three  or  four  hours,  the  supernatant  fluid  is  then  pipetted  off 
and  thoroughly  centrifuged.  To  this  is  then  added  one-fourth 
milHgram  of  salvarsan,  which  has  been  dissolved  in  sterile  water 
and  neutralized  in  the  usual  way.  This  is  thoroughly  mixed 
with  the  serum  and  then  the  serum  is  incubated  for  an  hour 
at  body  temperature  and  later  inactivated  at  a  temperature 
of  56°  C.  Usually  about  10  c.c.  of  this  serum  is  injected.  The 
patient  is  also  treated  by  means  of  ordinary  intravenous  injec- 
tions of  salvarsan.  A  method  which  has  been  developed  by 
Wardner  is  that  of  injecting  serum  obtained  by  the  Swift- 
Ellis  method  directly  beneath  the  intracranial  dura.  The 
objections  to  this  method  are  that  the  patient  must  be  an- 
esthetized and  trephined.  Another  method  has  been  devised 
by  Byrnes  which  consists  in  adding  bichlorid  of  mercury  to 
the  serum  instead  of  salvarsan.  The  blood,  about  six  ounces, 
is  withdrawn  and  the  serum  prepared  as  in  the  Ogilvie  method. 
One-fiftieth  of  a  grain  of  bichlorid  in  solution  is  then  added  and 
the  mixture  well  shaken  to  prevent  precipitation,  more  serum 
being  added  if  necessary. 

Opinions  differ  as  to  the  efl&cacy  of  the  various  methods  of 
treatment.  Cotton,  for  instance,  believes  that  salvarsanized 
serum  may  bring  about  definite  arrest  in  paresis.  Dunton  and 
Sargent,  on  the  other  hand,  state  that  the  duration  of  cases 
treated  with  salvarsan  is  less  than  normal.  Mott  is  of  the 
opinion  that  general  paralysis  has  not  been  cured  or  even  greatly 
benefited  by  salvarsan  or  neosalvarsan,  no  matter  how  admin- 
istered. Cotton,  again,  points  out  the  importance  of  treating 
cases  in  the  early  stages  and  that  treatment  must  be  persistent. 
Cotton  further  states  that  the  number  of  remissions  occurring 
under  salvarsan  is  very  much  greater  than  those  which  occur 
spontaneously  in  untreated  cases. 

The  Swift-Ellis  method  has  been  employed  very  extensively 


308  MENTAL    DISEASES 

in  my  own  clinic  in  given  cases  with  decided  improvement.  Re- 
missions of  more  or  less  length  have  been  established,  and  in  a 
few  instances  these  have  proved  of  such  long  duration  that  they 
suggest  that  perhaps  a  permanent  impression  has  been  made. 
However,  the  fact  that  extensive  remissions  occur  sponta- 
neously and  that  untreated  cases  of  paresis  may  have  a  very  long 
duration,  forbids  a  too  sanguine  expectation.  It  is  perhaps 
significant,  in  my  own  experience,  that  improvement  has  been 
most  pronounced  in  cases  whose  condition  was  not  so  advanced 
as  to  necessitate  asylum  commitment.  In  the  asylum  cases 
the  results  of  treatment  have  been  far  less  evident. 

As  an  early  result  of  the  treatment,  we  frequently  note  an 
improvement  in  the  mental  symptoms  and  especially  a  reduction 
in  the  pleocytosis  of  the  cerebrospinal  fluid.  Great  caution 
must,  however,  be  exercised  in  drawing  our  inferences.  The 
late  Thomas  B.  Earley  and  myself  treated  in  my  service  a  number 
of  cases  by  intraspinous  injections  of  unsalvarsanized  serum,  the 
serum  having  been  prepared  and  inactivated  in  the  usual  way 
without  the  previous  intravenous  injection  of  salvarsan.  To 
our  great  surprise  this  method  was  also  followed  by  a  fall  in  the 
lymphocyte  count  and  the  patients  themselves  also  showed 
improvement.  Finally,  Gilpin  and  Earley  tried  in  my  clinic  the 
effects  of  simple  spinal  drainage,  and  with  truly  remarkable 
results.  At  first  they  practised  spinal  drainage  before  giving 
the  intravenous  salvarsan  injection  in  the  hope  of  favorably 
influencing  the  diffusion  of  the  salvarsan  into  the  dural  sac. 
Later  they  instituted  simple  spinal  drainage  alone.  The  im- 
provement was  most  striking,  as  might  have  been  expected, 
in  tabes,  but  was  also  very  evident  in  paresis.  The  patients 
are  put  to  bed  and  drained  of  every  possible  drop  of  fluid  about 
once  in  two  weeks.  There  is,  of  course,  a  relief  for  the  time  being 
of  the  increased  intradural  pressure,  but  it  is  very  probable 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     309 

that  drainage  results  in  a  kind  of  lavage  of  the  dural  space, 
because  the  spinal  fluid,  as  we  know,  is  rapidly  replaced.  In 
keeping  with  this  there  is  also  a  fall  in  the  lymphocyte  count. 
Further,  there  must  normally  be  a  balance  between  the  blood- 
pressure  in  the  vessels  within  the  cord  and  the  pressure  of  the 
cerebrospinal  fluid.  If  the  pressure  of  the  cerebrospinal  fluid 
be  increased,  it  will  follow  that  the  vascularity  of  the  cord  will 
be  diminished;  less  blood  than  normally  wiU  be  able  to  enter 
its  vessels.  It  would  appear,  therefore,  that  the  rapid  with- 
drawal of  the  cerebrospinal  fluid  will  be  followed  by  an  increase 
in  the  vascularity  of  the  cord  and,  other  things  equal,  of  the 
brain  as  well.  Probably  the  results — often  truly  remarkable — 
which  follow  radical  spinal  drainage  are  to  be  attributed  to  the 
improved  nutrition  following  this  increased  vascularity.  In  other 
words,  we  have  here  a  parallel  to  the  results  of  the  Bier  method 
in  surgery.  Finally,  it  should  be  added  that  we  have  never 
noted  any  untoward  results  from  spinal  drainage  in  either  paresis 
or  tabes.  That  the  diagnosis  should  definitely  exclude  brain 
tumor  and  abscess  goes,  of  course,  without  saying. 

It  is  difficult  also  to  eliminate  the  factor  of  the  effect  of  the 
mere  trauma  of  the  intradural  methods.  Relatively  sUght 
and  sometimes  more  pronoimced  traumata,  as  past  experience 
has  shown,  stimulate  the  resistance  of  the  patient,  cause  hmi  to 
react,  and  to  be  better  for  a  time.  Intercurrent  infections  have, 
at  times,  a  similar  result.  Pilcz,  taking  advantage  of  this  fact,. 
has  inoculated  his  patients  with  cultures  of  erj^sipelas,  and  in  the 
resulting  reaction  has  noted  the  appearance  of  more  or  less  pro- 
nounced remissions. 

The  above  facts  are  of  the  very  greatest  significance  and  they 
are  in  keeping  with  the — for  the  time  being — brilliant  results 
occasionally  achieved  by  rest  methods  alone,  by  methods  which 
force  up  the  nutrition  of  the  patient  and  stimulate  his  defensive 


310  MENTAL    DISEASES 

reactions.  (See  Part  IV.)  It  is,  whenever  practicable,  important 
to  combine  the  salvarsan  or  other  special  method  of  treatment 
with  a  systematic  course  of  rest  treatment  in  bed. 

Finally,  in  order  that  the  patient  should  receive  the  benefit 
of  every  possible  means  at  our  command,  it  is  important  that  in 
the  intervals  of  the  salvarsan  therapy  he  should  be  thoroughly 
treated  with  mercurials  and  perhaps  iodids;  especially  is  this 
true  of  the  mercurials.  Regarding  the  latter,  however,  it  must 
be  borne  in  mind  that  the  resistance  to  mercury  is  greatly 
diminished  in  a  patient  under  salvarsan  therapy,  and  that 
the  too  free  use  of  the  mercurial  may  be  followed  by  a  serious 
involvement  of  the  gums  and  teeth,  by  diarrheas  and  other 
toxic  symptoms.  This  is  one  of  the  most  remarkable  facts 
attending  the  use  of  salvarsan.  Ordinarily  it  is  practically 
impossible  to  make  a  pronounced  mercurial  impression  upon  a 
paretic  and  yet  under  salvarsan  he  becomes  relatively  sensitive 
to  the  action  of  the  remedy. 

It  is  evident,  when  all  the  facts  are  considered,  that  the 
treatment  of  paresis  is  still  most  unsatisfactory.  The  germ  is 
deeply  embedded  in  the  nerve  substance  and  is  practically  be- 
yond our  reach.  It  is  probable  that  the  improvements  observed 
are  due  to  the  favorable  action  of  the  various  medicines  upon 
such  of  the  spirochetes  as  are  accessible  in  the  membranes  and 
vessels.  Only  such  a  remedy  as  would  be  readily  diffusible 
through  the  tissues  and  which  would  exercise  its  toxic  action 
upon  the  germ  without  injury  to  the  host — as  quinin,  for  in- 
stance, acts  in  malaria — would  fill,  it  would  seem,  the  conditions 
presented  by  the  problem  of  paresis. 

CEREBRAL    SYPHILIS 

Cerebral  syphilis  of  the  exudative  form  is  not  accompanied  by 
any  special  group  of  mental  symptoms.   Indeed,  in  the  great  mass 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     311 

of  cases,  mental  symptoms  are  absent.  The  patient  presents 
the  general  symptoms  of  headache,  somnolence,  and  possibly 
optic  neuritis,  together  with  special  symptoms  dependent  upon 
the  sites  of  lesions.  These  special  symptoms  consist  of  palsies, 
e.g,,  hemiplegia  and  cranial  nerve  palsies  of  various  kinds;  it  may 
be  that  epilepsies  are  present  owing  to  involvement  of  the  motor 
area,  but  of  purely  mental  symptoms  we  meet  with  but  few. 
That  in  long-standing  cases  of  diffuse  cerebral  involvement  men- 
tal weakness — a  certain  degree  of  dementia — may  supervene 
need  hardly  be  pointed  out.  The  resemblance  of  such  cases  to 
paresis  is,  however,  very  remote.  The  physical  signs  of  the 
latter  affection  are  usually  conspicuous  by  their  absence. 
Notably  is  this  the  case  with  the  tremor  of  tongue  and  hps,  the 
atactic  speech,  the  twitching  of  the  facial  muscles,  the 
faint  changing  and  fugitive  incoordination  of  movement  and 
allied  phenomena.  The  pupillary  phenomena,  also,  more  fre- 
quently consist  of  gross  dilatation  of  one  pupil,  associated,  it  may 
be,  with  other  frank  oculomotor  palsies.  An  Argyll-Robertson 
pupil  should  always  suggest  parenchymatous  syphilis,  i.  e., 
paresis.  The  picture  is  a  radically  different  one.  The  so-called 
cases  of  pseudoparesis  are  rejected  by  the  writer  as  not  belong- 
ing to  syphilis  of  the  exudative  form,  but  are  frankly  classified  by 
him,  in  accordance  with  an  increasing  experience,  with  paresis; 
they  are  really  paretics.  If  they  be  followed,  the  special  symp- 
toms of  paresis  become  more  and  more  apparent;  they  are  not 
cured  by  treatment,  and  the  outcome  is  the  same.  It  would  seem 
that  in  a  small  percentage  of  cases  of  paresis — as  is  every  now 
and  then  the  case  in  tabes — the  special  degenerative  changes 
taking  place  are  also  accompanied  by  late  though  active  gum- 
matous deposits  still  taking  place  in  vessels  and  membranes. 
Perhaps  we  have  to  do  here  with  a  double  infection,  i.  e.,  two 
strains  of  the  spirochete.     Such  cases  are,  however,  none  the 


312  MENTAL    DISEASES 

less  cases  of  paresis,  and,  as  just  pointed  out,  are  no  more  in- 
fluenced by  treatment  as  regards  the  eventual  result  than  are 
ordinary  cases  of  paresis. 

MULTIPLE  CEREBROSPINAL  SCLEROSIS 
Pronounced  mental  symptoms  in  association  with  multiple 
cerebrospinal  sclerosis  are  infrequent.  However,  they  are  met 
with  occasionally,  and,  it  would  appear  that  this  is  more  likely 
to  occur  when  the  cortex  is  especially  involved  in  the  disease 
processes.  Very  curiousty,  the  mental  symptoms  occurring  in 
multiple  cerebrospinal  sclerosis  may  be  inconstant  and  shifting, 
and  may  partake,  in  this  respect,  of  the  same  remarkable  pecu- 
liarity of  the  other  sjTiiptoms.  Just  as  palsies  come  and  go,  so 
may  the  mental  symptoms  come  and  go. 

When  present  the  mental  symptoms  are  those  of  a  dementia; 
sometimes  hallucinations  are  present.  Occasionally  there  is  a 
very  remarkable  simulation  of  the  symptoms  of  paresis.  The 
tremor  may  not  be  coarse  and  widely  atactic,  but  may  resemble 
that  of  paresis,  and  this  may  also  be  the  case  with  the  speech. 
At  the  same  time,  a  tj^jical  expansive  mental  state  maj^  make 
its  appearance.  That  errors  of  diagnosis  may  be  made  under 
such  circumstances  is  not  surprising.  After  a  time  the  mental 
symptoms  may  recede  and  a  mild  dementia  with  some  depres- 
sion may  remain.  As  the  disease  progresses,  the  signs  of  mul- 
tiple cerebrospinal  sclerosis  assert  themselves  and  the  diagnosis 
becomes  clear.  The  Wassermann  reaction,  too,  is  persistently 
negative.  The  true  nature  of  the  case,  however,  may  not  be 
recognized  until  the  autopsy. 

ARTERIOSCLEROSIS 

Arteriosclerosis  often  exists  in  a  marked  degree  without 
there  being  any  mental  sjTnptoms  of  moment;  this  is  time  and 
again  the  case  when  the  autopsy  reveals  a  marked  atheroma 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     313 

of  the  vessels  of  the  base.  However,  symptoms  do  make  their 
appearance  in  given  cases,  and  it  is  extremely  probable  that  in 
such  instances  the  smaller  and  finer  cerebral  vessels,  those  which 
supply  the  cortex,  are  also,  or,  it  may  be,  especially  involved. 
The  cortex  may  then  suffer  because  of  the  serious  interference 
with  its  blood  supply. 

The  symptoms  when  present  are  those  of  ready  mental  fatigue, 
loss  of  energy,  and  spontaneity.  In  addition,  the  patient  may 
be  easily  disturbed  and  irritable.  Further,  he  can  no  longer  do  as 
much  work  nor  can  he  do  it  as  well  as  formerly.  Memory  also 
becomes  somewhat  impaired.  At  times  he  is  somewhat  sleepy 
and  even  somnolent  during  the  day;  at  others  the  sleep  at  night 
is  much  disturbed,  and  even  a  well-marked  insomnia  may  be 
present.  Very  often  the  patient  complains  of  dizziness  or  suf- 
fers from  attacks  of  faintness.  Quite  frequently,  also,  he 
complains  of  numbness  or  of  paresthesias  of  the  feet  and 
legs  or  it  may  be  of  the  fingers.  The  reflexes  are  never  char- 
acteristically changed;  sometimes  normal,  sometimes  a  little 
exaggerated,  less  frequently  diminished.  The  pupils  are  nor- 
mal. In  some  cases  the  mental  symptoms  are  more  pronounced. 
In  such  cases  the  latter  suggest  those  of  a  premature  senility, 
there  being  a  simple  and  uncomplicated  mental  loss  more  or 
less  marked.  In  other  cases,  again,  the  patient  complains  of 
headache  or  other  distressing  sensation  in  the  head,  and,  in 
addition  to  the  lessened  capacity  for  work  and  impairment 
of  memory,  may  be  apathetic  or  slightly  confused  and  hallucina- 
tory; rarely  the  confusion  is  marked;  still  more  rarely  does  he 
have  attacks  of  stupor.  At  other  times  the  patient  is  agitated, 
or  it  may  be  depressed,  fearful,  and  suspicious.  He  may  even 
evolve  persecutory  ideas.  At  times  a  melancholia  is  simulated 
and  attempts  at  suicide  are  known  to  occur.  The  toxic  symp- 
toms present  are  doubtless  to  be  referred,  in  part  at  least,  to 


314  MENTAL    DISEASES 

associated  interstitial  changes  in  the  kidneys;  possibly  also  in 
the  liver  and  other  organs. 

Now  and  then,  in  arteriosclerosis,  apoplectiform  crises  or, 
less  frequently,  epileptiform  seizures  are  observed.  These  may 
be  accompanied  or  followed  by  hemiplegias  or  other  palsies. 
The  latter  may  be  temporary,  and  the  attack  may  suggest  a 
serous  apoplexy  rather  than  one  due  to  hemorrhage  or  ob- 
struction. At  such  times  aphasia  and  other  localized  phenom- 
ena may  be  present. 

The  age  of  patients  suffering  from  cerebral  arteriosclerosis 
with  mental  symptoms  ranges  from  about  fifty  to  sixty  years. 
The  patients  finally  die  of  myocarditis,  nephritis,  broncho- 
pneumonia, or  some  other  complication;  or,  a  cerebral  hemor- 
rhage, thrombosis,  or  embolism  may  occur,  followed  by  the 
usual  train  of  associated  symptoms. 

HEMORRHAGE,  EMBOLISM,  AND  THROMBOSIS 
When  mental  symptoms  occur  in  a  case  of  focal  vascu- 
lar lesion  of  the  brain,  they  constitute  a  group  added  to  those 
ordinarily  presented  by  the  lesion  in  question.  Thus,  there 
is  usually  a  hemiplegia  with  the  common  physical  signs;  if 
right-sided,  aphasia  in  some  form  is  present.  Such  patients 
may,  in  addition,  reveal  general  mental  enfeeblement,  due 
to  the  general  arterial  degeneration  present  in  such  brains. 
Quite  commonly  mental  impairment,  if  evident  previous  to  a 
cerebral  apoplexj^,  becomes  more  pronounced  subsequent  to 
such  an  attack;  in  other  words,  the  local  lesion  may  depress 
the  nutrition  of  the  brain  as  a  whole.  These  symptoms  are 
generalized  in  character  and  resemble  those  due  to  arterio- 
sclerosis. A  mental  feebleness,  impairment  of  memory,  irri- 
tability, and  occasionally  a  tendency  to  depression  and  tears 
are   noted.     Not   infrequently   the   dementia   becomes   quite 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     315 

pronounced.  At  times,  also,  a  mild  confusion  may  supervene; 
at  others,  states  of  excitement  with  hallucinations  and  delusions. 
On  the  whole,  however,  marked  disturbances  are  infrequent. 
It  is  not  necessary  to  point  out  that  dementia  should  be 
clearly  differentiated  from  the  aphasia  or  apraxia  that  may  be 
present.  While  aphasia  is  itself,  as  pointed  out  by  Marie,  an 
intellectual  deficit,  it  must  not  be  confused  with  that  general- 
ized loss  of  mental  faculties  which  constitutes  a  dementia. 

BRAIN    TUMOR    AND    BRAIN    ABSCESS 

In  many  cases  of  brain  tumor  the  symptoms  are  limited  to 
headache,  vomiting,  vertigo,  optic  neuritis,  and  such  focal 
symptoms  as  may  be  present  when  the  tumor  involves  areas  of 
the  cortex  which  yield  special  reactions,  such  as  focal  epilepsy, 
aphasia,  astereognosis,  hemianopsia,  and  the  like.  In  about 
two-thirds  of  all  cases  mental  phenomena  are  added.  The 
latter,  in  the  larger  number,  are  general  in  character,  and 
doubtless  depend  upon  causes  which  affect  the  function  of 
the  cerebrum  in  its  entirety,  such  as  increase  of  the  intra- 
cranial pressure,  interference  with  the  arterial  supply  or  the 
venous  return;  in  some  cases  an  intoxication  of  the  cortex,  the 
result  of  the  secretion  of  poisonous  substances  by  the  tumor 
or  of  its  degeneration,  seems  to  be  present.  The  patient  is 
apt  to  be  dull,  heavy,  obtunded.  There  may  be  a  distinct  mental 
diminution,  depression,  and  torpor.  The  patient  is  relaxed,  in- 
different, forgetful,  lacks  normal  spontaneity,  tires  quickly,  loses 
both  the  capacity  and  the  initiative  for  work.  Often  he  is 
childish,  silly,  causelessly  cheerful.  Sometimes  he  is  stupid, 
drowsy,  somnolent.  He  may  be  decidedly  confused;  even 
hallucinations  may  be  present.  Sometimes  a  fictitious  memory, 
a  tendency  to  fabrication,  as  in  Korsakow's  psychosis,  is  noted. 
Mental  impairment  may  be  very  evident.     In  given  cases  the 


316  MENTAL    DISEASES 

patient  is  much  dazed,  and  may  assume  automatic  or  catatonic 
attitudes. 

Brain  tumors  vary  greatly  as  to  the  degree  in  which  these 
general  symptoms  are  present.  There  are  some  cases  in  which 
they  never  make  their  appearance,  even  though  the  growth 
itself  be  large.  Quite  commonly,  too,  when  present,  they  are 
relatively  insignificant  and  of  little  moment.  It  would  appear 
that  the  rate  of  development  of  the  tumor  is  at  times  a  factor  of 
moment;  general  mental  symptoms  are  sometimes  entirely 
absent  when  this  is  slow.  Again,  the  degree  of  the  involvement 
of  the  cortex,  either  directly  or  indirectly,  as  by  invasion  by  the 
growth,  involvement  of  the  pia  in  inflammatory  processes,  or  the 
possible  action  of  toxins  upon  adjacent  portions  of  the  cortex, 
are  factors  which  also  influence  the  appearance  of  mental 
symptoms. 

The  mental  symptoms  vary  somewhat,  or  present  special 
features,  according  to  the  cortical  areas  or  other  portions  of  the 
brain  involved.  Thus,  the  majority  of  observers  are  agreed  that 
tumors  of  the  frontal  lobe  are  apt  to  present  greater  intellectual 
disturbances  than  growths  elsewhere;  there  is  a  greater  mental 
obtusion,  a  greater  interference  with  memory.  Sometimes, 
as  in  one  of  my  own  cases,  the  symptoms  at  first  sight  suggest 
paresis.  In  addition,  a  distinct  tendency  to  form  unexpected  as- 
sociations, to  make  puns  and  jests  may  be  present;  a  symptom 
which  the  Germans  have  called  "Witzelsucht."  Pfeifer,  how- 
ever, denies  that  these  symptoms  are  any  more  pronounced  with, 
frontal  tumors  than  with  tumors  elsewhere.  He  regards,  in 
left  frontal  tumor,  aphasic  symptoms  as  of  value;  also  impair- 
ment of  the  static  function.  Sometimes  ataxia  is  a  symptom 
of  frontal  tumor,  though  this  is  of  course  not  a  mental  symptom. 

Tumors  of  the  motor  area  are  manifested  by  focal  convulsive 
attacks    and    other    purely    focal    neurologic    features.     The 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     317 

general  mental  symptoms  of  brain  tumor  may  also  be  present; 
it  would  appear  that  in  addition  such  patients  are  a  little 
more  irritable,  become  excited,  depressed,  or  angry  more 
readily — just  as  does  the  ordinary  epileptic — than  when  the 
tumor  is  situated  elsewhere.  However,  this  factor  must  be 
regarded  as  of  doubtful  value.  Tumors  of  the  parietal  lobe 
may  be  accompanied  by  such  localizing  phenomena  as  astereog- 
nosis;  there  may  be  distinct  psychic  losses  in  the  recognition 
and  interpretation  of  foreign  bodies  by  touch.  These  symp- 
toms, however,  belong  to  the  domain  of  nervous  phenomena 
rather  than  of  insanity.  If  the  tumor  be  in  the  left  parietal 
lobe,  and  contiguous  to  or  pressing  upon  the  temporal  lobe, 
aphasic  symptoms  may  be  present.  In  the  left  temporal  lobe 
sensory  aphasic  symptoms,  in  addition  to  the  general  mental 
symptoms  of  brain  tumor,  may  be  present.  In  such  instances, 
if  the  mental  symptoms  be  pronounced,  the  clinical  picture 
may  be  quite  complicated.  In  occipital  tumors,  such  well- 
known  phenomena  as  hemianopsia,  alexia,  optic  aphasia,  may 
be  observed.  Special  mental  symptoms  can  hardly  be  said  to 
be  present,  save  that  visual  hallucinations — even  in  patients 
who  are  entirely  bhnd — may  occur;  one  of  my  patients  had 
frequent  dreams  with  vivid  scenes  and  pictures.  On  the 
whole,  it  may  be  said  that  hallucinations,  both  of  hearing  and 
vision,  occur  more  frequently  in  tumors  of  the  occipitotem- 
poral regions. 

Tumors  limited  to  the  centrum  ovale  are  not  apt  to  present 
mental  symptoms;  however,  if  they  be  large,  mental  impairment 
general  in  character  may  be  noted.  Tumors  of  the  callosum  may 
present  somnolence,  confusion,  ready  fatigue,  and  frequently 
very  marked  general  mental  loss;  probably  there  is  a  distinct 
relation  of  these  facts  to  the  degree  of  destruction  of  the  great 
commissural  fibers  connecting  the  corresponding  areas  of  the 


318  MENTAL    DISEASES 

two  hemispheres.  Diplegia,  incomplete  and  asymmetric,  may 
be  one  of  the  neurologic  findings.  Pfeifer  regards  the  men- 
tal symptoms  of  tumors  of  the  callosum  as  of  general  value 
only,  and  does  not  look  upon  them  as  distinctive.  Tumors  of 
the  pons  and  crura  are  rarely  attended  by  mental  changes. 
Cerebellar  tumors  are  sometimes  attended  by  general  mental 
symptoms,  doubtless  because  of  the  general  intracranial  dis- 
turbances caused  by  these  growths  when  large;  mild  confusion 
and  even  hallucinations  have  been  noted. 

It  is  important  to  add  that  every  now  and  then  hysteric 
symptoms  are  present  in  brain  tumor,  and  may  be  so  pronounced 
as  to  mask  the  underlying  disease  and  lead  to  errors  of  diagnosis. 
In  conclusion,  it  may  be  said  that  the  mental  symptoms  proper 
which  accompany  brain  tumor  are  in  a  sense  adventitious;  only 
occasionally  can  they  assist  in  the  diagnosis.  The  latter  must 
be  chiefly  based  upon  the  well-known  classical  signs  and  local- 
izing symptoms.  It  is  important,  however,  to  know  that 
mental  symptoms,  pronounced  in  character — even  delirium — 
may  complicate  the  otherwise  orderly  clinical  picture. 

Brain  abscess  may  be  attended  by  hebetude  and  more  or 
less  marked  obtusion.  Sometimes  confusion  is  present;  the 
patient  does  not  know  where  he  is,  does  not  understand  what 
is  said  to  him,  is  restless,  resisting,  delirious.  Most  frequently 
active  mental  phenomena  are  absent.  Occasionally,  and  this 
is  most  important,  convulsions  are  present  which  may  simulate 
epilepsy,  on  the  one  hand,  or  hysteria  on  the  other. 

TABES 

Following  the  discovery  of  the  Treponema  palHdum  by 
Schaudin  and  the  still  more  convincing  discovery  by  Noguchi 
of  the  parasite  in  the  brains  of  paretics,  the  tendency  was  at 
first  to  conclude  that  all  nervous  syphilis  is  the  same  (see  p.  294) 
and  also  to  break  down  the  distinguishing  landmarks  between 


MENTAL   DISEASE   RELATED   TO    SOMATIC   AFFECTIONS         319 

paresis  and  tabes.  It  has  become  necessary  to  emphasize  the 
distinction  between  the  two  great  parenchymatous  or — to 
employ  an  old  term — parasyphilitic  affections.  The  general 
distinction  between  tabes  and  paresis  has  long  been  admitted; 
it  is  the  occurrence  of  taboparesis — i.  e.,  the  form  in  which 
spinal  symptoms  appear  early — which  has  tended  to  obscure 
the  subject.  The  knee-jerks  may  in  taboparesis  be  much  dimin- 
ished or  even  lost.  If  at  the  same  time  incoordination  is  notice- 
ably absent,  the  picture  of  a  tabes  with  httle  or  no  ataxia  may 
be  simulated.  However,  certain  striking  differences  obtain 
between  taboparesis  and  tabes.  In  the  first  place,  the  history 
of  tabes  is  one  of  very  slow  and  gradual  evolution.  There  is  a 
history  of  difficulty  of  walking  in  the  dark,  of  unsteadiness  in 
the  mornings  while  washing  the  face,  of  shooting  pains  more  or 
less  severe,  of  gastric  crises,  of  delayed  sensation  in  the  feet 
and  legs,  of  disturbances  of  micturition.  Early,  too,  the  ataxia 
becomes  a  marked  feature.  Finally,  pupillary  disturbances 
make  their  appearance.  These  differ  notably  from  those  met 
with  in  paresis.  Most  frequently  they  consist  of  a  narrowing 
of  the  pupils,  i.  e.,  a  myosis,  with  an  early  impairment  or  loss 
of  the  light  reaction.  It  is  to  be  especially  noted,  further,  that 
in  tabes  the  pupils  are  equal;  inequahty  is  excessively  rare. 
Finally,  the  impairment  of  the  light  reaction  is  the  same  on 
the  two  sides;  sluggishness  and  the  degree  of  loss  are  not  more 
pronounced  on  one  side  than  on  the  other. 

In  taboparesis,  the  evolution  of  the  symptoms  may  be  some- 
what slow,  but,  as  a  rule,  it  is  far  more  rapid  than  in  tabes.  Men- 
tal S3n2iptoms  also  make  their  appearance,  so  that  the  real  nature 
of  the  case  early  becomes  apparent.  Again,  incoordination 
though  present  in  taboparesis  is  rarely  so  pronounced  as  to  play 
a  striking  role.  The  writer  has  never  in  a  case  of  taboparesis 
ehcited  as  a  beginning  symptom  a  history  of  difficulty  of  walking 


320  MENTAL    DISEASES 

in  the  dark  or  of  unsteadiness  in  the  mornings  while  washing 
the  face.  Shooting  pains  also  form  no,  or  a  very  inconspicuous, 
part  of  the  early  history,  and  at  no  time  do  they  constitute  a 
prominent  or  striking  feature.  Gastric  and  other  crises,  it  may 
be  safely  stated,  are  excessively  rare.  Delayed  sensation 
in  the  feet  and  legs  is  equally  absent;  at  most  a  mild  hy- 
pesthesia,  widely  diffused  but  not  attended  by  delay  is  ob- 
served. Disturbances  of  micturition  also  form  no  feature  of 
the  early  history  of  taboparesis.  Further,  the  disturbances  of 
the  pupil  in  paresis  are  peculiar.  Long  before  the  light  reaction 
disappears,  it  is  noted  that  the  pupils  are  unequal,  the  opposite 
condition  to  that  met  with  in  the  great  mass  of  true  tabes.  This 
inequality  may  be  shifting  in  character,  absent  at  one  time, 
present  at  another.  At  the  same  time  it  may  be  noted  that  one 
or  both  pupils  are  irregular  in  shape.  A  pupil  may  be  oval, 
ovoid,  or  its  circumference  may  be  irregular,  the  circle  may  be 
slightly  flattened  as  by  a  cord,  or  it  may  be  slightly  angled. 
This  irregularity,  like  the  inequality,  is  usually  changing  and 
shifting,  present  at  times  and  absent  at  others ;  the  pupil  may 
indeed  change  its  shape  while  under  observation  and  thus  justify 
the  designation  "ameboid  pupil."  Finally,  the  two  pupils  may 
react  unequally  to  light;  the  reaction  may  upon  one  side  be 
prompt  and  normal,  upon  the  other  sluggish  or  lost.  In  tabes 
the  changes  in  the  pupils  consist  for  the  most  part  in  symmetrical 
departures  from  the  normal  both  in  size  and  light  reaction.  The 
reason  for  this  is  probably  to  be  sought  in  the  fact  that  in  tabes 
the  myosis  and  fixation  are  to  be  attributed  to  changes  in  the 
cord,  while  in  paresis  they  are  directly  due  to  involvement  of 
the  brain — of  the  oculomotor  nuclei  and  of  the  intracranial 
mechanism  upon  which  the  shape  and  movements  of  the  pupils 
depend.  In  short,  tabes  stands  in  bold  contrast  to  paresis  both 
in  its  course  and  final  termination. 


MENTAL   DISEASE   RELATED   TO    SOMATIC   AFFECTIONS         321 

In  the  great  majority  of  cases  of  tabes  the  mental  condition 
is  good  throughout.  Many  instances  can  be  cited  of  tabetics 
who  fill  important  positions,  follow  pursuits  and  vocations  which 
demand  not  only  entire  sanity,  but  often  very  unusual  qualifica- 
tions. Among  them  we  find  physicians,  lawyers,  business  men, 
men  of  affairs.  Finally,  tabes  is  a  disease  of  a  life-time,  not  of  a 
few  years,  as  in  paresis;  and  when  tabetics  die,  they  do  not  die 
of  a  dementia,  but  of  disease  of  the  heart,  of  the  aorta,  of  an 
arteriosclerosis,  of  infections  of  the  bladder,  of  disease  of  the 
kidneys,  or  other  visceral  compUcations.  There  is  nothing  in 
tabes  itself — at  least  this  is  the  uniform  result  of  clinical  experi- 
ence— which  leads  to  mental  change.  When  such  changes  not- 
withstanding supervene,  we  should,  other  things  equal,  revise 
our  diagnosis  to  that  of  paresis  of  the  ascending  form,  or  change 
altogether  to  that  of  an  exudative  rather  than  a  parasyphilitic 
affection;  i.  e.,  to  a  cerebrospinal  syphihs. 

Of  course  a  tabetic  patient  may  acquire  a  mental  disease  as 
may  any  other  person.  A  tabetic  who  uses  alcohol  to  excess 
may  pass  through  a  delirium  tremens  or  an  alcoholic  confusion. 
Sometimes  other  intercurrent  mental  maladies  are  observed. 
It  cannot  be  said,  however,  that  tabetics  possess  a  special  vul- 
nerability; thus  they  rarely  become  much  depressed,  in  spite 
of  their  pains  and  deplorable  condition.     Suicide  is  practically 

unknown  among  them. 

TRAUMA 

Severe  trauma  of  the  head  may  be  followed  by  transient  or' 
persistent  mental  symptoms.  The  patient  may  be  dazed, 
partially  stunned,  or  there  may  be  complete  loss  of  conscious- 
ness from  concussion.  If  the  injury  has  been  moderate  in 
severity,  the  patient  may  merely  turn  pale,  become  dizzy, 
confused,   may   stagger   and   perhaps   fall.     Usually,    after   a 

21 


322  MENTAL    DISEASES 

variable  period  of  quiet,  he  recovers  from  the  blow  and  subse- 
quently presents  no  symptoms,  save  perhaps,  for  a  time,  head- 
ache and  indisposition  for  exertion.  Frequently  no  symptoms 
whatever  persist.  If  the  blow  has  been  severe,  the  patient 
falls  to  the  ground  unconscious  and  presents  the  physical  signs 
of  shock.  He  is  very  pale,  his  extremities  cold  and  moist,  and 
the  pulse  very  weak  and  rapid.  Sometimes  he  will  respond 
when  spoken  to  loudly,  but  usually  his  answers  are  unintelli- 
gible. The  degree  of  unconsciousness  varies,  of  course,  with  the 
violence  and  the  damage  to  the  intracranial  contents,  and  this 
is  also  true  of  the  detailed  physical  signs.  If  there  has  been  no 
extensive  extravasation  of  blood  there  will  be  no  palsies ;  some- 
times, however,  convulsions  are  observed.  The  pupils  are 
commonly  dilated,  though  they  may  be  contracted ;  if  unilateral 
hemorrhage  exists,  as,  for  instance,  from  the  middle  meningeal, 
there  may  be  a  dilated  pupil  on  the  same  side  (Hutchinson's 
pupil).  If  there  have  been  no  gross  lesions,  the  patient  usually 
reacts  and  becomes  conscious  within  twenty-four  hours.  Fre- 
quently he  vomits  as  the  reaction  comes  on.  Usually,  too,  the 
patient  complains  of  headache  and  vertigo. 

It  is  probable  that  blows  sufficient  to  give  rise  to  concussion 
are  followed  by'  actual  damage  to  the  cranial  contents,  mem- 
branes, vessels,  and  brain  substance.  In  the  case  of  the  mem- 
branes and  vessels,  we  probably  have  to  deal  with  contusions 
and  minute  hemorrhages,  and,  in  the  case  of  the  brain  sub- 
stance, with  changes  which,  though  less  understood,  are 
probably  also  structural  in  their  nature.  It  is  not  surpris- 
ing, therefore,  that  mental  symptoms  may  persist  after  the 
patient  has  recovered  from  the  immediate  effects  of  the 
accident. 

The  patient  may  be  more  or  less  confused  for  days,  weeks, 
or  even  months  following  a  severe  concussion.     The  confusion 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS      323 

may  be  severe,  but  usually  it  is  mild  in  type,  accompanied  by 
headache,  dizziness,  and  other  distressing  sensations.  Some- 
times the  patient  has  no  recollection  of  the  accident  or  of  the 
events  of  some  hours  or  a  day  or  more  preceding;  i.  e.,  there  is 
present  a  retro-anterograde  amnesia.  The  patient  is  also  irri- 
table, depressed,  and  usually  slow  in  response.  As  time  goes 
on  he  usually  improves;  the  improvement,  however,  may  be 
very  slow.  In  other  cases  permanent  mental  weakness  results, 
a  true  traumatic  dementia. 

Instead  of  the  picture  of  a  confusion  supervening,  a  delirium 
may,  after  some  days,  make  its  appearance.  It  is  extremely 
probable  that,  when  this  is  the  case,  an  inflammatory  reaction 
involving  the  membranes  or  possibly  the  brain  substance  has 
taken  place;  i.  e.,  that  a  localized  traumatic  meningitis  or 
encephalitis  has  developed. 

It  is  important  to  differentiate  confusion  and  delirium  the 
result  of  actual  physical  injury  of  the  cranial  contents,  from  the 
purely  functional  nervous  disturbances  which  sometimes  follow 
the  fright  or  psychic  shock  of  an  accident.  The  latter  do  not 
differ  from  the  functional  troubles  ensuing  from  accidents  in 
which  the  head  is  in  no  way  involved.  As  a  rule,  they  assume 
the  form  of  hysteria;  quite  commonly  they  prove  of  little 
consequence  unless  there  is  present  the  element  of  litigation. 
True  mental  disease,  other  than  the  confusion,  delirium,  and 
dementia  resulting  from  destructive  injury  of  the  cranial  con- 
tents, never  supervenes.  Fright,  such  as  leads  to  hysteria, 
never  produces  mental  disease.  It  is  perfectly  true  that  persons 
suffering  from  hysteria  may  also  be  depressed  and  nosophobic, 
but  I  have  never  observed  a  real  psychosis  develop  in  such  a 
case.  Melancholia,  for  instance,  is  never  caused  by  trauma; 
not  even  can  the  value  of  an  exciting  cause  be  ascribed  to 
trauma.    One  of  my  own  patients,  who  had  suffered  from  several 


324  MENTAL    DISEASES 

attacks  of  melancholia,  each  one  of  which  had  necessitated  her 
commitment  to  an  asylum,  suffered  during  one  of  her  normal 
intervals  from  a  trolley  accident  in  which  she  received  a  rather 
severe  blow  on  the  head.  She  developed  subsequently  not  a 
melancholia,  but  a  typical  hysteria;  one,  too,  which  persisted 
for  many  months  until  litigation  ceased,  when  it  finally  disap- 
peared. What  is  true  of  melancholia,  it  need  hardly  be  added, 
is  also  true  of  the  other  psychoses.  For  instance,  if  a  dementia 
prsecox  is  discovered  in  a  patient  following  a  trauma,  it  is  safe 
to  infer  that  the  mental  affection  antedated  the  accident;  or  in 
any  event  that  a  causal  relation  does  not  obtain. 

6.  PREGNANCY,  PARTURITION,  THE  PUERPERIUM,  LACTATION 
Pregnancy,  labor,  the  puerperal  state,  and  the  subsequent 
suckling  of  the  offspring  being  basic,  racial  functions,  and  in 
themselves  essentially  and  intrinsically  normal,  cannot  of  them- 
selves cause  insanity.  Other  facts  must  of  necessity  play  more 
or  less  important  roles  in  the  etiology.  Principal  among  these 
is  that  of  a  neuropathy,  usually  inherited;  quite  commonly  we 
eUcit  a  history  of  mental  disease  in  the  ancestry,  and  at  times 
even  a  history  of  mental  breakdowns  occurring  in  the  women 
of  a  family  at  the  puerperal  periods.  It  is  observed,  too,  that 
patients  who  have  passed  through  attacks  of  insanity  inde- 
pendently of  pregnancy  may  again  become  insane  when  a 
puerperal  period  supervenes.  This  does  not,  however,  neces- 
sarily follow ;  in  a  case  of  manic-depressive  insanity,  for  a  long 
time  under  my  observation,  the  patient  passed  several  times 
through  pregnancy  without  incident;  indeed,  she  seemed  to  be 
more  nearly  normal  at  these  times  than  at  others. 

In  the  causation  of  the  mental  breakdowTis  there  may  be,  in 
addition  to  a  pre-existing  neuropathy,  also  the  factor  of  ex- 
haustion.     This    exhaustion    may    follow    previous    disease, 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     325 

long-continued  overwork  or  nervous  overstrain;  that  is,  it 
may  follow  a  pregnancy  occurring  in  an  already  greatly  de- 
bilitated patient.  More  powerful,  however,  than  exhaustion 
are  fright,  shock,  grief,  and  especially  the  worry  and  shame 
incident  to  an  illegitimate  pregnancy.  Finally,  into  insanity 
occurring  in  the  lying-in  period  there  may  enter  the  factor  of 
infection. 

The  insanity  which  supervenes  during  pregnancy  may  mani- 
fest itself  shortly  after  conception,  though  much  more  fre- 
quently it  comes  on  much  later,  that  is,  about  the  sixth  or 
seventh  month.  In  some  women  there  is,  after  conception  has 
occurred,  an  irritability,  a  change  in  character  and  disposition, 
which  persists  during  the  first  few  weeks — sometimes  during 
the  first  two  or  three  months.  Not  infrequently  this  is  ac- 
companied by  an  unwonted  or  exaggerated  degree  of  nausea 
and  vomiting;  at  times,  also,  by  unusually  marked  perversions 
or  "longings"  as  to  the  food  which  the  patient  desires.  Ordi- 
narily these  symptoms  sooner  or  later  disappear;  indeed, 
rather  early  in  most  cases.  Rarely,  however,  distinct  mental 
symptoms  make  their  appearance.  In  such  case  the  patient 
becomes  depressed,  perhaps  confused,  and  gives  way  to  painful 
delusions  of  ill-treatment,  abandonment  and,  it  may  be,  of 
being  illegitimately  pregnant;  sometimes  hallucinations  make 
their  appearance.  As  a  rule,  the  mental  disturbances  of  the 
early  period  are  rather  mild  in  type;  rarely  is  there  excitement; 
i.  e.,  the  clinical  picture  is  usually  that  of  a  mild  confusion  with 
painful  depression;  delirium  is  infrequent.  The  actual  fact 
of  illegitimate  pregnancy,  with  its  attendant  worry  and  suffer- 
ing, may,  in  given  cases,  be  a  powerful  contributing  factor; 
however,  it  is  not  of  itself  sufficient  in  an  otherwise  healthy 
woman  to  produce  insanity;  it  may,  it  is  true,  eventuate  in 
suicide  or  other  tragedy,  but  this  is  not  the  outcome  of  disease. 


326  MENTAL    DISEASES 

Mental  symptoms  making  their  appearance  in  the  early 
period  of  pregnancy,  say  before  the  fourth  month,  usually 
disappear  long  before  pregnancy  is  terminated,  and  the  labor 
and  lying-in  period  may  in  such  cases  progress  in  an  entirely 
normal  manner.     There  are,  of  course,  exceptions  to  this  rule. 

When  the  symptoms  appear  in  the  second  half  or  later 
months  of  pregnancy,  the  clinical  picture  is  similar,  save  that 
the  symptoms  are  more  pronounced.  The  depression  and 
confusion  are  more  marked,  and  the  hallucinations  and  delu- 
sive ideas  are  more  insistent.  They  are  of  the  same  painful 
character,  and  deal  with  abuse,  ill-treatment,  abandonment, 
illegitimacy,  denial  of  paternity,  and  the  like.  Finally,  the 
mental  symptoms,  instead  of  disappearing,  frequently  persist 
after  pregnancy  has  terminated,  at  least  until  the  puerperium 
has  been  completed  and  sometimes  longer.  On  the  whole, 
it  should  be  added  that  insanity  of  pregnancy  is  rare.  When 
occurring  it  is  not  improbable  that  the  patient,  for  some  as  yet 
unexplained  reason,  suffers  from  a  toxic  metaboUsm.  The 
prognosis  is  almost  uniformly  good. 

Not  infrequently  the  insanity  met  with  during  pregnancy 
is  spoken  of  as  a  melancholia,  a  term  which  is  obviously  in- 
correct. A  patient  in  the  depressive  phase  of  a  manic- 
depressive  cycle  may,  of  course,  pass  through  a  pregnancy, 
but,  as  already  pointed  out,  a  causal  relation  does  not  obtain. 
Similarly  a  pregnancy  may  occur  in  the  course  of  a  dementia 
praecox,  in  which  case  hebephrenic,  catatonic,  or  paranoid 
phenomena  may  make  their  appearance  during  the  pregnancy 
or  subsequently.  It  would  be  obviously  incorrect  to  attribute 
the  insanity  in  such  a  case  to  the  pregnancy,  the  puerperium, 
or  the  subsequent  lactation.  On  the  other  hand,  pregnancy 
seems  at  times  to  hasten  or  to  favor  the  development  of  a  demen- 
tia praecox,  as  though  a  disturbed  metabolism  or  exhaustion  of 


MENTAL    DISEASE    RELATED    TO    SOMATIC    AFFECTIONS     327 

the  sex  glands  played  a  role.  (See  also  p.  131.)  Obviously,  be- 
cause of  the  unfavorable  prognosis  of  dementia  prsecox,  its 
proper  recognition  under  these  circumstances  is  of  the  utmost 
importance. 

Every  now  and  then  mental  symptoms  make  their  appearance 
during  parturition.  The  shock  and  excitement  of  labor  may 
in  a  neuropathic  individual  be  accompanied  or  followed  by  a 
delirium.  Usually  such  a  delirium  is  of  brief  duration.  It  is 
only  when  uremic  or  convulsive  phenomena  are  also  present 
that  the  symptom  is  of  consequence.  Ordinarily  the  delirium 
is  transient  and  of  little  significance.     Further,  it  is  very  rare. 

The  insanity  that  supervenes  during  the  lying-in  period  is 
alike  the  most  frequent  and  the  most  important.  As  in  the 
insanity  of  pregnancy,  there  is  a  previously  existing  neurop- 
athy; toxic  elements  are,  however,  very  important  factors. 
After  delivery  there  is  a  marked  change  in  metabolism;  the 
enlarged  uterus  undergoes  rapid  involution  and  absorption, 
while  the  mammary  glands  become  engorged  and  active.  It 
is  not  improbable  that,  owing  to  an  abnormal  metabolism,  a 
defective  reaction  of  the  glands  of  internal  secretion,  an  imper- 
fect oxidation,  or  other  cause,  large  amounts  of  toxic  substances 
find  their  way  into  the  circulation.  Rarely  does  infection  play 
a  role;  time  and  again  cases  are  observed  in  which  neither  the 
general  nor  the  local  signs  of  infection  are  present;  that  is, 
neither  rise  of  temperature  nor  the  physical  evidences  of  infec- 
tion of  the  genital  tract.  Exhaustion,  shock,  and  fright  also 
play  a  varying  role. 

Puerperal  insanity  is  often  spoken  of  as  puerperal  mania;  in 
reality  it  is  not  a  mania,  but  a  delirium.  It  is  more  frequent 
after  the  birth  of  the  first  child;  again,  it  occurs  somewhat 
more  frequently  in  persons  who  begin  bearing  children  late; 


328  MENTAL    DISEASES 

finally,  attacks  not  infrequently  recur  with  each  succeeding 
pregnancy,  though  this  is  not  invariable. 

The  onset  is  preceded,  as  a  rule,  by  certain  suggestive  symp- 
toms. The  patient  ceases  to  do  well;  she  becomes  anxious, 
nervous,  irritable,  and  depressed;  at  times  she  manifests  an 
unnatural  aversion  for  the  child  or  for  the  husband.  She  loses 
her  appetite,  the  skin  is  pale,  and  the  bowels  constipated. 
She  becomes  sleepless  and  great  weakness  makes  its  ap- 
pearance. The  milk  and  lochia  usually  become  diminished 
or  suppressed,  though  in  some  cases  they  are  not,  at  first  at 
least,  markedly  influenced.  Finally,  after  a  variable  period, 
delirium  makes  its  appearance.  Sometimes  prodromata  are 
not  observed,  and  in  such  case  the  mental  symptoms  make 
their  appearance  suddenly.  Usually  the  onset  occurs  within 
the  first  two  weeks,  quiet  frequently  as  early  as  the  fifth  or 
sixth  day,  or  it  may  be  not  until  the  ninth  or  tenth  day ;  after  the 
patient  has  begun  to  leave  her  bed. 

At  the  time  of  the  onset  the  patient  becomes  obtunded  and 
confused,  and  hallucinations,  illusions,  and  delusions  make 
their  appearance.  Soon  an  active  delirium  supervenes  which 
reaches  a  high  degree  of  intensity;  the  patient  becomes  greatly 
excited  and  noisy.  Hallucinations  of  vision  are  numerous  and 
vivid;  this  is  also  true  of  hallucinations  of  smell ;  those  of  hear- 
ing seem  to  be  less  prominent.  The  delusions  are  unsystematized, 
changing,  and  fragmentary.  The  picture  presented  does  not 
differ  from  that  seen  in  ordinary  delirium.  (See  p.  46.)  As  a 
rule,  puerperal  delirium  persists  with  great  activity  for  several 
days  or  possibly  a  week  or  two,  after  which  the  intensity  of  the 
excitement  is  somewhat  less,  and  the  symptoms  persist  as  an 
active  confusion  (see  p.  50)  for  several  months;  four  months 
is  not  unusual,  and  much  longer  periods  are  frequent.  Some- 
times the  excitement  is  moderate  throughout  and  convales- 


MENTAL    DISEASE   RELATED    TO    SOMATIC    AFFECTIONS     329 

cence  begins  after  six  or  eight  weeks.  Such  a  favorable  course 
is,  however,  unusual.  After  a  time  the  excitement  diminishes, 
the  confusion  becomes  less  pronounced,  the  patient  begins 
to  recognize  her  surroundings,  and,  lastly — and  most  important 
of  all — begins  to  reahze  that  she  has  been  ill,  takes  her  food 
willingly,  and  convalescence  becomes  established.  The  symp- 
toms and  course  of  an  attack  var}^  greatly  in  different  cases.  The 
prognosis  of  puerperal  insanity  is  almost  uniformly  good.  How- 
ever, exhaustion  sometimes  becomes  extreme,  and  second  and 
third  attacks  are  less  promising  than  the  first.  Visceral  compli- 
cations are  infrequent. 

Every  now  and  then,  in  persons  of  a  neuropathic  history  or 
make-up,  insanity  makes  its  appearance  during  the  period  of 
lactation.  Usually,  several  months  elapse  before  the  symp- 
toms are  observed.  As  a  rule  the  patient  passes  through  a 
prodromal  period  of  exhaustion,  and,  toward  the  third  or  sub- 
sequent months  of  nursing,  the  patient  becomes  much  depressed, 
confused,  and  hallucinatory;  in  other  words,  the  patient  passes 
through  an  attack  of  confusion  with  painful  hallucinations  and 
delusions.  Quite  commonly  the  excitement  is  moderate  in 
degree,  though  it  may  be  subject  to  marked  exacerbations  in 
which  the  patient  is  much  agitated.  The  delusions  betray 
nothing  characteristic;  they  are  fragmentary,  changeable  and 
always  painful  and  distressing.  The  confusion  does  not  differ 
from  that  met  -mth.  in  the  other  exhausted  states.  (See  p.  49.) 
Sometimes  there  is  fear  of  impending  death ;  sometimes  aversion 
to  the  child.  That  the  patient  should  be  promptly  separated 
from  the  child  need  hardly  be  pointed  out.  The  duration  of 
the  insanity  of  lactation  is  always  a  number  of  months — three, 
four,  or  longer.  Its  pathology,  also,  is  clearly  that  of  a  toxic 
metabolism. 


CHAPTER  II 
MENTAL  DISEASES  AS  RELATED  TO  AGE 

Having  studied  the  clinical  forms  in  which  mental  disease 
presents  itself,  and  the  relation  of  these  forms  to  the  somatic 
affections,  it  is  next  in  order  to  approach  the  subject  from 
the  standpoint  of  age.  In  so  doing,  we  will  pass  over  ground 
much  of  which  is  familiar,  but  some  of  which  is  new. 

Age  may  be  conveniently  divided  into  six  periods : 

(1)  Infancy,  the  period  from  birth  to  puberty; 

(2)  Adolescence,  the  period  from  puberty  to  adult  age; 

(3)  Early  Adult  Age; 

(4)  Matiu-e  Adult  Age; 

(5)  Middle  Age;  and 

(6)  Old  Age. 

Such  a  division,  though  largely  arbitrary,  is  clinically  useful. 

When  we  take  up  the  period  of  infancy,  we  find  at  once  that 
the  subject  resolves  itself  into  a  consideration,  first,  of  insanity 
in  children  and,  second,  of  mental  deficiencies  the  result  of 
arrested  development  or  gross  pathologic  conditions. 

INSANITY  IN  CHILDHOOD 
Insanity  in  childhood  is  excessively  rare.  It  must  be  clearly 
differentiated  from  idiocy  and  imbeciUty.  Insanity,  we  will 
remember,  consists  in  a  change  in  the  quality  of  mind;  i.  e., 
a  change  in  the  manner  of  thinking,  acting,  and  feeling,  while 
idiocy  and  imbecihty  are  states  of  quantitative  defect.  It  is  a 
remarkable  fact  that,  as  regards  mental  diseases,  the  influence 
of  heredity  does  not  make  itself  felt  in  a  decided  way  until 

330 


MENTAL    DISEASES    AS    RELATED    TO    AGE  331 

after  puberty  or  until  adult  life  is  reached.  However,  children 
sometimes  present  suggestive  premonitory  signs.  Thus,  in- 
stead of  presenting  the  purely  objective  and  aggressive  attitude 
of  the  normal  mind  in  childhood,  the  child  may  be  seK-con- 
scious  and  introspective.  It  may  manifest  excessive  shyness, 
self -distrust,  unreasonable  fear.  It  may  be  morbidly  conscien- 
tious; it  may  make  premature  profession  of  religion,  may  con- 
fess to  imaginary  sins,  or  may  manifest  a  veritable  religious  ex- 
altation. At  times  the  manic-depressive  make-up  is  distinctly 
foreshadowed.  Typical  melancholia  and  typical  mania  are, 
however,  excessively  rare.  It  should  be  added  that  suicide  in 
childhood  is  also  very  infrequent.  When  children  commit 
suicide  they  do  so  usually  to  avoid  punishment,  to  avoid  the 
consequences  of  some  act  of  disobedience,  or,  it  may  be,  to  es- 
cape cruelty.  Sometimes  the  act  is  originally  a  pretence  to 
excite  sympathy,  pity,  or  mercy,  but  in  which  the  pretence  is 
carried  too  far.  Rarely,  if  ever,  is  the  suicide  the  result  of 
ideas  of  self-accusation  or  of  the  unpardonable  sin. 

Sometimes  the  child  develops  tics,  little  tricks  of  movement, 
habit  spasms,  or  other  symptoms  strongly  suggestive  of  the 
neurasthenic-neuropathic— the  psychasthenic — disorders.  (See 
Part  I,  Chapter  VI.)  Less  frequently  it  manifests  a  well- 
defined  special  fear,  a  well-defined  indecision  or  abouha.  As 
a  rule,  when  such  symptoms  are  present  in  children  they  are, 
as  we  have  seen  (loc.  cit.),  generalized  in  type. 

Again,  very  rarely,  dementia  prsecox  appears  before  puberty. 
In  one  of  my  own  cases  the  patient,  a  boy,  manifested  clearly 
the  depressive  and  hallucinatory  phase  at  eight  years  of  age; 
the  hallucinations  were  many  of  them  very  vivid ;  those  of  hear- 
ing were  in  part  described  as  pistol-shots,  and  were  attributed 
to  men  who  were  trying  to  kill  the  patient. 

Equally  rare  is  the  condition  which  Sander  has  described  as 


332  MENTAL    DISEASES 

"originare  Verriicktheit,"  paranoia  originaria.  At  a  very 
early  age  the  child,  in  whom  a  neuropathic  heredity  is  usually 
quite  pronounced,  presents  an  introspective  attitude  of  mind. 
He  is  less  happy,  less  cheerful  than  other  children.  He 
is  morbidly  sensitive  and  easily  irritated  or  depressed.  Often 
he  suffers  from  dreams  which  seem  to  prolong  themselves 
into  the  waking  period.  Soon  he  beUeves  that  he  is  being 
neglected  by  his  parents,  that  he  is  not  being  treated  as  well 
as  his  brothers  and  sisters.  At  the  same  time  it  is  noted — and 
this  is  a  striking  feature  of  his  case — that  he  is  precocious  sex- 
ually. This  precocity  is  characterized  by  erotic  dreams  and 
erotic  ideas,  and  may  also  be  accompanied  by  premature 
physical  sexual  development.  At  the  same  time  delusions, 
at  times  persecutory  and  at  times  expansive,  manifest  them- 
selves. As  in  paranoia  of  the  adult,  the  patient  may  believe 
that  he  is  born  of  a  great  family,  that  he  has  been  substituted  in 
the  cradle,  that  great  riches  and  a  great  future  lie  before  him. 
The  progress  of  the  affection  is  often  interrupted  by  intervals 
of  improvement;  often  the  course  is  very  irregular.  In  time 
mental  weakness,  more  or  less  pronounced,  supervenes  and  a 
dementia  terminates  the  picture.  The  symptoms  suggest 
that  we  have  here  to  do  with  a  very  early  form  of  dementia 
praecox;  possibly,  as  Kraepelin  thinks,  a  rapidly  deteriorating 
hebephrenia.  The  unusual  sexual  precocity  points  strongly  to 
disease  of  the  pineal  gland,  and  it  is  not  impossible  that  disease 
of  the  internal  secretions,  more  especially  hyperpinealism,  plays 
here  a  role.  The  relation  between  pineal  excess  and  sexual 
precocity,  a  knowledge  of  which  we  owe  especially  to  von 
Frankl-Hochwart,  makes  such  a  view  highly  probable. 

In  addition  to  the  mental  disturbances  above  noted,  children 
of  course  suffer  from  the  mental  affections  of  the  first  group — 
delirium,  confusion,  and  stupor.     Delirium,  as  met  with  in  the 


MENTAL    DISEASES    AS    RELATED    TO    AGE  333 

febrile  periods  of  the  exanthemata  and  other  infections,  is  the 
common  mental  disturbance.  This  has  already  been  suffi- 
ciently considered.  (See  p.  35.)  Occasionally  a  protracted  ex- 
citement with  delirium  follows  shock  or  fright.  Confusion,  too, 
more  or  less  persistent,  may  succeed  a  delirium,  or  may  make  its 
appearance  during  the  postfebrile  period  of  one  of  the  exan- 
themata, but  it  is  quite  rare.  This  is  also  true  of  stupor,  though 
the  latter  is  met  with  somewhat  more  frequently;  e.  g.,  after 
typhoid  fever. 

Finally,  children,  the  victims  of  inherited  syphilis,  may  pre- 
sent a  dementia  or  may  suffer  from  juvenile  paresis.    (See  p.  270.) 

IDIOCY    AND    IMBECILITY 

Idiocy  and  imbecility  are,  as  already  pointed  out,  states  of 
mental  deficiency.  The  idiot  is  a  child  in  whom  this  deficiency 
is  gross  and  is  evident  at  birth  or  within  a  short  period  after 
birth;  i.  e.,  a  few  months,  two  or  three  years.  The  imbecile 
is  one  in  whom  the  deficiency  does  not  become  apparent  until 
much  later;  not  until  a  number  of  years  have  passed — it  may 
be,  not  until  puberty  is  reached  or  until  adolescence  is  well 
advanced.  The  law,  we  will  remember  (see  p.  21),  defines 
the  idiot  as  a  child  born  without  mind  and  the  imbecile  as  an 
adult  with  the  mind  of  a  child.  Both  definitions,  as  already 
pointed  out,  are  excessive,  and  yet  are  useful  as  accentuating 
the  essential  features  of  the  two  conditions.  However,  a 
sharp  distinction  cannot  be  drawn  between  idiots  and  imbeciles^ 
and  in  practice  we  are  in  the  habit  of  grouping  them  together 
under  the  general  caption  of  feeble-minded  children;  quite 
commonly,  too,  the  entire  group  is  spoken  of  as  idiots,  who  are 
then  classified  in  accordance  with  the  degree  of  their  mental 
deficiency  into  low-grade,  middle-grade,  and  high-grade  idiots. 
Such  a  classification  enables  teachers  to  group  together  cases 
requiring  similar  kinds  of  management  and  training.     A  more 


334  MENTAL    DISEASES 

comprehensive  classification,  however,  one  which  enables  the 
physician  to  at  once  place  a  given  case  in  its  proper  nosologic 
relations,  and  which  the  writer  has  employed  for  many  years, 
is  the  folloAving: 

1.  Idiocy  presenting  general  morphologic  changes;  i.  c, 
arrests  of  development  and  deviations. 

2.  Idiocy  presenting  gross  pathologic  lesions  of  the  nervous 
system;  e.  g.,  the  hemiplegic  and  diplegic  idiots. 

3.  Cretinism. 

4.  Amaurotic  family  idiocy. 

MORPHOLOGIC   IDIOCIES 

The  idiots  with  morphologic  abnormalities  are  those  in 
whom  the  organism  has  failed  to  unfold  or  develop  either  in  the 
normal  manner  or  to  the  normal  degree.  They  present,  other 
things  equal,  anomalies  of  the  head,  features,  trunk,  and  limbs, 
all  expressive  of  arrest  or  deviation.  Thus,  the  head  may  be 
unusually  small,  the  forehead  unusually  low  and  narrow,  the 
palate  deep,  irregular  and  narrow,  the  dentition  defective  or 
anomalous,  the  lobes  of  the  ears  absent  or  confluent  with  the 
cheek,  the  pinna  irregular,  expanded,  crushed  or  flaring,  with  per- 
haps an  exaggerated  Darwinian  tubercle.  Similarly  the  nose 
may  be  altered  in  shape,  flattened,  sunken  in  the  bridge,  or  the 
nares  divergent.  The  digits  may  show  irregularities  of  length 
and  development,  as  may  also  the  limbs  and  the  trunk.  If  the 
opportunity  presents  itself  of  examining  the  brain,  the  latter 
may  be  found  to  be  abnormally  small  (microcephalic),  to  present 
an  unusual  paucity  or  simplicity  of  fissures  and  convolutions; 
or  anomalies  of  fissures  and  convolutions  may  be  observed 
suggesting  conditions  met  with  normally  in  the  apes  and  mon- 
keys. In  short,  the  idiot  with  morphologic  stigmata  is  analo- 
gous to  a  bud,  which,  owing  to  some  inherent  defect  in  growth 


MENTAL    DISEASES    AS    RELATED    TO    AGE  335 

— an  agenesis — or,  owing  to  the  retarding  influence  of  dis- 
ease inherited  or  congenital,  is  withered  or  is  deflected  from 
its  normal  pathway  of  development. 

Among  the  most  interesting  forms  in  the  group  of  morphologic 
idiots  are  those  in  whom  the  outward  appearance  simulates 
that  of  some  race  of  mankind  other  than  that  from  which  the 
patient  springs.  The  most  frequent  of  these  is  that  known  as 
MongoHan  idiocy.  In  this  there  is  an  unusual  degree  of  brachy- 
cephaly,  together  with  an  unusual  lateral  expansion  and  height 
of  forehead;  often  there  is  also  a  certain  obliquity  of  the  palpe- 
bral fissures.  The  Chinese-like  appearance  of  these  children 
is  often  very  striking.  In  other  cases  there  is  a  distinct  negroid 
shape  of  the  skull  and  of  the  features,  and  even  at  times  an 
unusual  pigmentation  of  the  skin.  Other  racial  forms,  such  as 
the  Malay  and  Red  Indian  types,  have  been  described;  I  have 
not,  however,  myself  seen  clearly  marked  instances  of  these. 

PATHOLOGIC    IDIOCIES 

Idiots  with  gross  pathologic  changes,  such  as  hemiplegia 
and  diplegia,  occur  TVT.th  considerable  frequency.  There  is 
always  present  a  lesion  of  one  or  both  hemispheres,  involving, 
among  other  parts,  the  motor  area.  Quite  commonly  the  lesion 
has  its  origin  in  difficult  and  delayed  labor;  indeed,  the  cases 
are  often  spoken  of  as  birth-palsies.  They  are  frequently  due 
to  prolonged  compression  or  constriction  of  the  head,  in  which 
there  is  a  more  or  less  extensive  extravasation  of  blood  over 
one  or  both  hemispheres.  The  hemorrhage  appears  to  arise 
from  the  veins,  near  or  at  their  entrance  into  the  superior 
longitudinal  sinus.  In  cases  which  reach  autopsy  extensive 
hemorrhage  is  found  over  the  vertex,  on  one  or  both  sides;  it 
may  extend  downward  over  the  lateral  aspect  and  anteriorly 
and  posteriorly  to  a  variable  degree.     If  the  child  survives,  a 


336  MENTAL    DISEASES 

hemiplegia  or  diplegia  follows,  due  to  failure  of  the  upper  motor 
neurones  and  tracts  to  develop.  A  similar  arrest  takes  place 
in  the  adjacent  areas.  Occasionally  marked  loss  of  substance 
occurs,  together  with  the  formation  of  a  cyst,  which  extends 
from  the  general  brain  surface  downward  to  a  variable  depth; 
a  so-called  porencephalus.  Sometimes  there  is  atrophy  and 
sclerosis;  the  sclerosis  may  be  confined  to  a  few  convolutions 
or  may  be  widely  diffused. 

Much  less  frequently  the  hemiplegia  or  diplegia  does  not 
arise  at  the  time  of  birth,  but  occurs  subsequently  and  then 
usually  has  its  origin  in  some  infection.  Thus,  it  has  been 
known  to  occur  during  or  following  scarlet  fever,  measles, 
whooping  cough,  diphtheria,  typhoid  fever.  We  have  here 
likewise  to  deal  with  damage  to  brain  tissue  secondary  to  in- 
volvement of  membranes  and  blood-vessels. 

Finallj^  more  rarely,  the  cerebral  palsy  is  prenatal  in  its  origin. 
In  some  cases  simple  prenatal  arrest,  an  abiogenesis,  seems  to  be 
the  causal  factor.  However,  pathologic  conditions  occurring  in 
intra-uterine  life,  such  as  ependymitis,  meningitis,  and  vascular 
lesions,  the  results  of  infections,  seem  to  be  the  more  common 
causes.    Some  of  these  cases  are  classified  under  Little's  disease. 

Occasionally  an  idiocy  due  to  gross  pathologic  change  finds 
its  explanation  at  the  autopsy  in  an  extensive  atrophy,  brain 
tumor,  or  other  gross  lesion,  such  as  hydrocephalus.  The 
symptoms  in  a  given  case  w\\\  or  will  not  include  those  of 
hemiplegia  in  accordance  with  involvement  or  absence  of  in- 
volvement of  the  motor  area  and  pathways. 

CRETINISM 

Cretinism  is  the  term  applied  to  myxedema  occurring  in 
children.  Like  myxedema  in  the  adult,  it  is  due  to  a  more  or 
less  marked  hypothyroidism.    (See  p.  245.)    The  thyroid  gland 


MENTAL    DISEASES    AS    RELATED    TO    AGE  337 

may  fail  to  develop  or  may  undergo  atrophy  before  birth;  i.  e., 
there  is  in  many  cases  a  congenital  thyroid  deficiency.  In 
others,  the  child  is  apparently  normal  at  birth  and  evidences  of 
thyroid  disease  may  not  be  noted  for  several  years;  usually,  how- 
ever, the  symptoms  appear  within  the  first  five  years,  excep- 
tionally only  are  they  delayed  as  late  as  puberty  or  adolescence. 

The  physical  signs  presented  by  the  cretin  are  very  striking. 
We  note  at  once  that  the  stature  is  much  dwarfed  and  that  the 
skin  everywhere  presents  a  diffuse  jelly-like  infiltration.  The 
latter  is  most  marked  in  the  face,  hands,  and  feet.  The  face 
is  rounded  and  swollen,  the  eyelids  are  puffy,  the  cheeks  and 
lips  distended;  the  bridge  of  the  nose  is  frequently  sunken  and 
the  nose  itself  broad  and  flat.  Often  the  tongue  is  enlarged 
and  protruding.  As  a  rule,  the  teeth  are  much  decayed.  The 
ears  are  apt  to  be  large  and  distorted.  The  skull  is  markedly 
brachycephalic  because  of  a  premature  union  of  the  basi- 
occipital  and  basisphenoid;  similarly,  the  shafts  of  the  long  bones 
fail  to  grow  because  of  a  tendency  of  the  diaphyses  and  the 
epiphyses  to  unite;  consequently  the  bones  of  the  limbs  tend 
to  increase  in  width.  The  hands  and  feet  are  much  flattened. 
There  are  diffuse  swellings  above  the  clavicles;  the  abdomen  is 
full  and  often  pendulous.  There  is  a  more  or  less  marked 
lordosis  of  the  lumbar  spine;  the  limbs  are  crooked;  the  move- 
ments slow  and  the  gait  awkward.  The  muscles  are  soft  and 
the  patient  has  little  strength. 

Should  the  child  survive  until  puberty  is  reached,  the  latter 
is  either  never  or  only  imperfectly  established.  Because  of 
the  mental  condition,  it  is  difficult  to  judge  of  the  special  senses. 
However,  taste,  smell,  and  hearing  appear  to  be  much  below 
normal;  this  is  also  the  case,  though  to  a  less  extent,  with  the 
perception  of  cutaneous  impressions;  vision  seems  to  suffer 
least  of  all. 

22 


338  MENTAL    DISEASES 

The  skin  is  dry  and  wrinkled,  the  hair  coarse  and  thick.  As 
a  rule,  no  hair  is  found  upon  the  body;  if  so,  it  is  very  scanty. 
Usually  no  thyroid  gland  can  be  felt;  on  the  other  hand,  now 
and  then  an  enlargement  is  noted.  The  temperature  is,  as  a 
rule,  slightly  subnormal;  while  the  pulse  and  respiration  are 
distinctly  slow. 

The  mental  condition  is  essentially  one  of  marked  deficiency. 
Many  of  the  patients  cannot  learn  to  talk,  are  incapable  of 
training,  cannot  stand  or  walk  unassisted,  and  are  filthy  in 
their  habits.  INIany  of  those  who  learn  to  talk  usually  sit  about 
unoccupied  without  interest  and  without  emotion.  Only  a 
few  are  capable  of  any  employment.  Their  mental  processes  are 
very  slow;  they  are  stupid,  often  sleep  a  great  deal,  and,  while 
usually  quiet,  may,  if  annoyed,  give  way  to  outbursts  of  anger. 

Different  patients,  of  course,  present  the  above  symptoms 
in  varying  degrees,  but,  as  a  rule,  the  latter  are  so  marked  as  to 
leave  no  doubt  as  to  the  diagnosis. 

AMAUROTIC   FAMILY   IDIOCY 

Amaurotic  family  idiocy  is  a  remarkable  affection,  for  a 
knowledge  of  which  we  are  indebted  to  B.  Sachs.  It  occurs 
almost  exclusively,  it  would  seem,  in  children  of  Polish-Jewish 
parentage,  and  commonly  in  a  number  of  children  in  the  same 
family.  The  patient  presents  nothing  unusual  at  birth,  but  in 
the  first  year,  more  frequently  between  the  fourth  to  the  tenth 
month,  begins  to  reveal  striking  changes.  It  becomes  weak 
and  relaxed,  cries  a  great  deal,  is  indifferent,  ceases  to  look  about, 
and  no  longer  grasps  at  objects.  It  does  not  see  as  before.  Its 
weakness  becomes  progressively  worse.  Soon  it  is  no  longer 
able  to  sit  up,  to  hold  up  its  head,  and  later  to  swallow  properl3\ 
Not  infrequently  wasting  and  contractures  make  their  appear- 


MENTAL    DISEASES    AS    RELATED    TO    AGE  339 

ance  in  the  muscles.  The  tendon  reflexes  are  commonly  in- 
creased; less  frequently,  they  are  normal  or  absent.  Sometimes 
a  Babinski  reflex  is  noted  and  at  others  a  persistent  extension 
of  the  great  toe. 

An  examination  of  the  eye-grounds  reveals  optic  atrophy  to- 
gether with  remarkable  appearances  in  the  region  of  the  macula 
lutea,  namely,  a  red  spot  surrounded  by  a  dull  white  area.  Nys- 
tagmus, rolling  and  restlessness  of  the  eyeball,  may  be  present; 
also  automatic  irregular  or  rhythmic  movements  of  the  tongue 
and  lips;  drooling.  Hearing  likewise  becomes  impaired  and 
probably  the  other  special  senses  also.  There  is  a  rapid  and  in- 
creasing mental  loss,  which  is  after  a  time  complete.  Marasmus 
and  finally  death,  in  the  second  or,  at  most,  third  year  of  life, 
complete  the  picture.  The  microscopical  findings  reveal  ex- 
tensive atrophic  degeneration  of  cells  and  fibers,  not  only  in 
the  cortex  but  in  the  brain  and  cord  generally. 

Spielmeyer  and  Vogt  have  described  a  somewhat  similar 
degenerative  affection  occurring  in  children  at  from  six  to  ten 
years.  The  children  deteriorate  mentally,  lose  interest,  become 
indifferent,  lose  their  memory,  become  filthy,  lose  their  speech, 
save  perhaps  a  few  articulate  expressions.  Bhndness  also  sets 
in,  which  finally  becomes  complete.  The  ophthalmoscope  reveals 
optic  atrophy.  Paralyses,  spasticity,  and  epileptic  seizures  may 
be  added.  The  affection  lasts  for  several  years.  Tuberculosis 
appears  to  terminate  the  picture.  The  microscopic  findings, 
as  in  the  infant  form,  consist  of  similar  degenerative  changes, 
though  much  less  profound.  Vogt  speaks  of  this  form  as  a  juve- 
nile form  of  amaurotic  family  idiocy.  However,  while  like  the 
infant  form  it  is  a  familial  disease,  it  is  not  especially  confined 
to  the  Jewish  race. 

Among  the  factors  which  play  a  part  in  the  etiology  of  feeble- 


340  MENTAL    DISEASES 

mindedness  in  general,  and,  it  would  appear,  especially  in  the 
etiology  of  the  morphologic  cases,  i.  e.,  those  with  simple  de- 
velopmental arrest,  we  have  various  diseases  and  pathologic 
states  in  the  ancestry.  Among  these  should  be  mentioned 
tuberculosis,  syphilis,  alcohi)lism,  insanity,  epilepsy,  and  other 
nervous  affections.  Exhausting  diseases  affecting  the  mother 
at  the  time  of  pregnancy  have  an  especially  baneful  influence. 
Consanguinity  in  neuropathic  stocks  is  also  a  serious  menace 
to  the  offspring;  although  it  should  be  added  that  in  healthy 
stocks  consanguinity  in  the  human  species  seems  to  be  no 
more  injurious  than  in  animals.  Premature  birth  is  another 
factor  occasionally  noted;  cortical  agenesis  or  arrest  is  not 
uncommon.  Among  the  congenital  hemiplegias  and  di- 
plegias, we  have  the  dystocia  and  cognate  factors  already 
considered.  Among  those  occurring  subsequent  to  birth  we 
have,  as  already  stated,  the  various  infectious  diseases  and 
traumata. 

The  duration  of  life  of  feeble-minded  children,  as  a  group, 
is  fortunately  not  great.  They  have,  on  the  whole,  a  greatly 
lessened  resistance  to  infection,  and  by  far  the  larger  number 
die  in  the  second  decade.  Barr's  statistics  show  that  a  few 
survive  to  the  third  decade,  a  very  small  number  to  the  fourth, 
and  almost  none  survive  to  a  later  period.  Among  the  common 
causes  of  death  are  tuberculosis,  pneumonia,  and  other  infec- 
tious diseases,  diseases  of  the  heart,  of  the  digestive  tract,  and 
of  the  kidneys,  as  well  as  various  affections  of  the  nervous 
system,  such  as  embolism,  thrombosis,  and  hemorrhage  of  the 
cerebral  vessels,  and  meningitis. 

The  treatment  of  feeble-minded  children  is,  of  necessity,  one 
of  simple  hygienic  management.  Little  can  be  expected  in 
any  case  from  the  internal  administration  of  remedies,  save 


MENTAL    DISEASES    AS    RELATED    TO    AGE  341 

in  the  single  instance  of  cretinism.  Here  desiccated  thyroid  is 
often  of  great  value.  If  the  treatment  be  instituted  early,  the 
child  begins  to  grow,  the  myxedematous  infiltration  disappears, 
the  torpor  vanishes,  and  the  child  becomes  alert  and  intellectu- 
ally active.  When  the  treatment  is  begun,  the  child  should 
be  put  to  bed;  the  initial  doses  of  the  thyroid  should  be  quite 
small,  say  one-fourth  of  a  grain  three  times  daily.  Gradually 
the  amount  should  be  increased  until  a  full  dose  is  reached, 
but  this  should  be  done  with  care  and  judgment.  The  change 
which  ensues  in  early  cases  is  often  remarkable;  in  patients 
in  whom  the  affection  has  existed  for  a  number  of  years  the 
improvement  is  less  decided;  especially  is  this  the  case  if  the 
treatment  has  been  delayed  until  puberty  or  adolescence  is 
reached.  Care  should  be  exercised,  especially  in  long-standing 
cases,  not  to  use  the  thyroid  too  freely. 

In  cases  of  feeble-mindedness,  in  which  inherited  syphilis 
is  clearly  the  etiologic  factor,  the  iodids  and  mercurials  un- 
fortunately yield  results  of  little  or  no  consequence.  In  other 
cases,  again,  in  which  the  bones  of  the  skull  seem  to  have  united 
prematurely,  surgical  procedures — such  as  craniectomy — 
intended  to  give  the  brain  a  greater  opportunity  of  growth  and 
expansion,  likewise  fail  of  result. 

The  method  of  treatment  usually  resorted  to  in  feeble- 
minded children  generally  is  that  of  special  training  and 
instruction.  In  many  cases  it  is  of  advantage  to  precede 
the  institution  of  a  special  plan  of  education  by  submitting 
the  child  to  a  series  of  mental  tests.  Of  the  various  tests  that 
have  been  devised  those  of  Binet  and  Simon  appear  to  be  the 
most  useful.  "Their  object  is  to  provide  a  quick  means  for 
the  psychologic  diagnosis  of  the  grade  of  intelligence  of  a  back- 
ward or  abnormal  child  by  means  of  thirty  tests  of  a  simple 
but  precise  character,  sufficiently  varied  in  type  to  explore 


342  MENTAL    DISEASES 

all  the  important  phases  of  intellectual  capacity  (with  special 
reference  to  judgment — good  sense,  initiative,  adaptability), 
and  of  such  a  kind  as  to  permit  an  intelUgent  uivestigator  to 
form  an  independent  estimate  of  the  child's  mental  equipment. 
The  tests  are  designed  to  measure  native  ability  rather  than 
erudition  or  scholastic  attainment.  They  are  to  be  admin- 
istered individually,  \\ith  suitable  precautions,  to  insure  the 
goodwill  and  active  co-operation  of  the  child,  and  to  avoid 
restraint  or  timidity."  (Whipple.^)  They  require  much  time 
and  patience,  and  should  be  applied  by  persons  who  have 
familiarized  themselves  with  the  method  by  practice.  It  is 
also  important  to  bear  in  mind  that  the  defective  child  is  very 
readily  fatigued,  and  that  recovery  from  fatigue  is  less  rapid 
than  in  the  normal  child. 

Very  commonly  general  principles  are  followed  in  the  train- 
ing, such  as  teaching  the  child,  if  filthy,  to  become  cleanly;  i.  e., 
to  give  the  evacuation  of  the  bladder  and  bowels  a  definite  and 
finally  normal  attention;  to  teach  the  child  to  stand,  to  walk, 
and  to  perform  other  movements  properly.  Drills  and  exercises 
improve  the  coordination.  By  appropriate  methods  speech 
is  encouraged  and  improved,  the  eyes  are  trained  to  see,  the  ears 
to  hear,  the  hands  to  feel.  Such  work  naturally  falls  to  the 
lot  of  the  trained  educator.  Sometimes,  in  individual  cases, 
much  is  accomplished;  on  the  whole,  however,  the  results  are 
meager.  Finally,  the  frequent  death  of  the  patients  in  the 
second  decade  of  life  sets  a  sad  limit  to  our  best  efforts. 

The  arrest  of  the  idiot  mind  is  usually  general  in  character; 
i.  e.,  the  various  faculties  of  the  mind  reveal  a  proportionate 
lack  of  development.  However,  quite  frequently  the  mental 
state  is  one  of  very  irregular  and  unequal  development. 
Thus,  every  now  and  then  the  idiot  child  is  unusually  pre- 
1  Whipple,  "  Manual  of  Mental  and  Physical  Tests,"  1910. 


MENTAL    DISEASES    AS    RELATED    TO   AGE.  343 

cocious  in  certain  directions  or  reveals  unusual  aptitudes  and 
powers.  Among  the  latter  are  the  so-called  learned  idiots, 
"idiots  savants."  Thus,  they  may  reveal  an  abnormal  memory; 
they  may  be  able  to  repeat  long  citations  of  the  meaning  of 
which,  however,  thej^  have  no  comprehension;  or,  it  maybe,  they 
will  acquire  phrases  and  often  long  quotations  in  foreign  lan- 
guages, of  the  meaning  of  which  they  are  likewise  ignorant. 
Sometimes  a  remarkable  memory  for  dates  is  revealed  or 
the  idiot  is  a  lightning  calculator,  or  perhaps  he  has  a  remark- 
able aptitude  for  music.  There  is,  however,  neither  originality 
nor  invention,  merely  automatic  reproduction;  finally,  if  the 
idiot  survives  until  adult  life  is  reached,  his  unusual  powers 
become  less  pronounced  or  even  disappear.  This  is  true  also 
of  the  feeble-minded  child  in  whom  the  faculties  have  suffered 
a  general  arrest ;  in  a  sense,  the  approach  toward  the  end  of  the 
second  decade  is  for  the  idiot  usually  a  period  of  degeneration. 

ADOLESCENCE 

We  have  already  fully  considered  the  principal  mental  dis- 
turbances of  the  adolescent  period;  namely,  the  various  forms 
of  dementia  prsecox.  At  this  period  of  life  we  may  also,  of 
course,  meet  with  the  delirium,  confusion  and  stupor  associated 
with  the  infections.  Pure  manic-depressive  states,  on  the  other 
hand,  are  rare.  The  neurasthenic-neuropathic  group — the 
psychasthenias — however,  are,  as  we  have  seen,  not  infrequent. 

EARLY  ADULT  AGE 
The  third  decade  of  life  is  pre-eminently  the  period  for  the 
first  appearance  of  mania  and  melancholia.  Dementia  prsecox 
is  also  met  with  at  this  time;  quite  frequently,  as  we  have  seen, 
the  third  decade  is  the  period  of  fatal  termination.  Delirium, 
confusion  and  stupor  from  infection  and  toxicity  are,  of  course, 


344  MENTAL    DISEASES 

also  met  with.  Paranoia  may  have  its  inception  at  this  age, 
and  this  is  also  true,  though  less  frequently,  of  paresis.  The 
neurasthenic-neuropathic  disorders  are  also  met  Tsith  with  con- 
siderable frequency. 

MATURE  ADULT  AGE 
Mature  adult  age — twenty-five  to  forty-five — is  a  period  in 
which  are  met  recurrent  attacks  of  mania  and  melanchoUa 
and  also  paranoia  and  paresis;  as  well,  of  course,  as  the 
disorders  dependent  upon  the  infections,  intoxications,  and 
cognate  causes.  The  neurasthenic-neuropathic  disorders  are 
somewhat  less  frequent  than  in  early  Ufe. 

MIDDLE  AGE 
The  form  of  mental  disease  met  with  most  frequently  at  the 
middle  period  of  life  is  the  melancholia  of  middle  age,  the  so- 
called  melancholia  of  involution.  That  this  is  but  a  part  of  the 
general  syndrome  of  ordinary  manic-depressive  insanity  is,  as 
we  have  pointed  out,  extremely  probable.  It  should  be  re- 
membered that  the  prognosis  of  middle  age  melanchoUa  is  less 
favorable,  both  as  regards  duration  and  as  regards  recovery, 
than  that  of  the  melanchoUa  of  early  life.  Again,  mania, 
though  infrequent,  is  not  unknown  at  this  period.  Hj^pomania 
occurs  somewhat  more  frequently  than  mania,  and  at  times 
is  accompanied,  especiaU}^  in  women,  by  a  marked  sexual  re- 
crudescence. Active  eroticism  may  manifest  itself  in  various 
ways;  e.  g.,  by  open  advances,  letters,  intrigues,  scandals,  love 
affairs,  or  marriage  with  men  very  much  younger  than  the  patient, 
by  elopements  and,  at  times,  by  open  breaches  of  conduct.  (See 
p.  103.)  The  other  mental  disorders  present  in  the  earlier  periods 
of  adult  life,  paranoia  and  paresis,  are  also  met  with  here. 
Paranoid  mental  states  in  which  delusions  of  persecution 
dominate  the  clinical  picture  are  by  no  means  uncommon. 


MENTAL   DISEASES    AS    RELATED    TO    AGE  345 

(See  p.  167;  also  Part  III,  Chapter  I.)  The  neurasthenic- 
neuropathic  disorders  are  infrequent.  Disturbances  due  to  the 
infections  and  intoxications  are  less  common;  those  due  to 
visceral  disease  perhaps  a  little  more  frequent  than  in  earlier  life. 

OLD    AGE 

Old  age  is  essentially  a  period  of  involution  of  nutrition,  of 
diminished  power  for  the  sustained  expenditure  of  energy,  and, 
commonly,  of  a  lessening  in  the  general  range  of  activities. 
The  organism  begins  to  reveal  gradual  and  increasing  changes 
in  its  structure,  all  of  them  expressive  of  senescence.  Noticeably 
is  this  the  case  with  the  heart  and  blood-vessels.  The  heart  no 
longer  has  the  power  to  drive  the  blood  with  its  former  energy^ 
while  the  vessels  present  walls  no  longer  soft  and  yielding, 
but  now  rigid  and  with  a  narrowed  lumen.  That  the  brain 
must  inevitably  betray  the  evidences  of  a  lessened  nutrition  is 
very  evident.  The  changes  of  function  that  ensue  are,  however, 
in  the  vast  majority  of  mankind  entirely  normal  and  in  no  sense 
pathologic.  There  is  a  quantitative  reduction,  but  this  is 
limited  in  degree,  so  that  the  individual  continues  to  discharge 
his  functions  normally  to  the  end  of  life.  It  is  only  when  this 
reduction  is  excessive,  and  especially  when  it  is  associated  with 
qualitative  changes,  that  it  becomes  pathologic. 

Senile  Dementia. — When  simple  and  excessive  reduction 
without  qualitative  changes  makes  its  appearance,  there  are 
present  the  phenomena  of  a  simple  senile  dementia;  they  con- 
stitute those  of  a  simple  primary  dementia.  (They  have 
already  been  considered  in  Part  I,  Chapter  VII.)  We  will  not 
here  rehearse  them;  suffice  it  to  say,  that  memory,  judgment, 
the  ability  to  do  work,  to  take  in  new  ideas,  and  to  properly 
coordinate  them  are  gradually  lost.  The  impairment  of 
memory  at  first  reveals  itself  by  mere  forgetfulness,  later  by 


346  MENTAL    DISEASES 

failure  to  remember  recent  events.  Gradually  the  defects 
grow  deeper;  the  period  of  middle  life  is  invaded,  and,  finallj', 
even  the  memories  of  early  life  and  youth  are  lost.  The  other 
mental  faculties  share  in  the  general  deterioration  until  finally 
a  more  or  less  marked  dementia  is  established.  The  patient 
is  childish,  is  usually  unable  to  attend  to  his  ovm  wants  and 
needs  personal  care. 

Senile  Confusion. — Senile  dementia  does  not  always  pre- 
sent itself  in  the  simple  and  uncomplicated  form;  indeed,  in 
perhaps  the  larger  number  of  cases,  other  s>Tnptoms  indi- 
cative of  quaUtative  mental  changes  are  added.  Thus,  to 
the  phenomena  of  diminished  nutrition  there  may  be  added 
those  of  toxicity  and  exhaustion,  and  in  such  cases  tiie  pict- 
ure of  senile  mental  loss  is  complicated  by  that  of  confu- 
sion. There  maj'  be  present  hallucinations  and  unsystema- 
tized delusions;  usually  both  hallucinations  and  delusions 
are  painful  in  character.  Occasionally  the  patient  refers  his 
hallucinations  to  the  persons  about  him,  begins  to  think  that 
his  neighbors,  friends  or  relatives  are  inimical  to  him,  are  trj-ing 
in  some  way  to  harm  or  injure  him  or,  perhaps,  to  kill  him. 
In  other  words,  he  may  acquire  a  distinctly  paranoid  or  perse- 
cutory attitude.  His  delusions  are,  however,  vaguely  system- 
atized, if  at  all.  Naturally,  also,  the  confusion  varies  greatly 
in  degree;  frequently  it  is  mild  and  passive;  at  other  times 
it  is  active,  and  ma}',  indeed,  give  way  now  and  then  to 
episodes  of  deUrium.  During  such  episodes  the  patient  may 
be  much  disturbed  and  excited,  and  such  a  case  is  some- 
times— incorrectlj',  of  course — spoken  of  as  senile  mania. 
Again,  a  patient  in  whom  confasion,  passive  or  active,  has  been 
noted,  may  at  another  time  be  relatively  clear,  presenting  then 
only  the  underlying  sjTnptoms  of   the  quantitative  loss,  the 


MENTAL    DISEASES    AS    RELATED    TO    AGE  347 

dementia.  Doubtless  the  confusion  has  its  origin  in  defective 
metabolism   and   defective   elimination. 

Senile  "Paranoia." — Every  now  and  then  patients  with  be- 
ginning senile  dementia  become  morbidly  sensitive  and  sus- 
picious.  Under  these  circumstances  the  care  and  ministra- 
tions of  relatives  and  friends  may  be  greatly  misinterpreted. 
The  patient  may,  on  the  one  hand,  acquire  the  notion  that 
the  son  or  daughter  who  is  so  devoted  is  merely  scheming 
to  get  his  (the  patient's)  money,  or,  on  the  other  hand,  a 
trifling  lapse  in  an  otherwise  assiduous  devotion  may  give 
rise  to  ideas  of  gross  indifference  and  neglect.  With  time 
such  ideas  may  acquire  all  the  force  of  fixed  delusions,  and 
it  is  not  surprising  that  under  these  circumstances  a  will  is 
sometimes  made  in  which  gross  injustice  is  done  to  the  child 
or  other  relative  who  is  the  most  deser\Tng.  Sometimes  the 
son  or  the  daughter  who  has  made  the  greatest  sacrifices — 
who  has  given  up  career,  success,  marriage — ^is  the  very  one 
who  suffers  most  from  the  caprice  and  injustice  of  the  testator. 
Quite  commonly  the  suspicions  and  delusions  of  the  latter  are 
concealed  during  his  lifetime.  Occasionally,  however,  he  com- 
municates them  in  secrecy  to  a  visitor  or  to  a  child  or  other 
relative  whom  he  sees  only  infrequently.  Sometimes  halluci- 
nations of  taste  and  smell  are  present  and  the  patient  believes 
that  he  is  being  poisoned.  Refusal  of  food  or  the  manner  of 
accepting  it  may  reveal  the  delusion,  or  the  latter  becoming 
insistent  the  patient  may  openly  accuse  those  about  him. 
Very  frequently,  though  it  is  noted  that  he  is  peculiar,  sus- 
picious, imtidy,  and  even  filthy,  and  that  he  is  forgetful,  un- 
reasonable, irritable,  and  childish,  his  actual  intentions — in- 
tentions based  upon  delusive  beliefs — may  not  become  known 
until  after  his  death. 

That  such  a  patient  not  infrequently  becomes  a  prey  to  de- 


348  MENTAL    DISEASES 

signing  persons  is  also  true.  Sometimes  it  is  a  child  or  other 
relative  who  ensconces  himself  behind  the  suspicions,  prejudices, 
and  delusions  of  the  patient,  and  influences  the  latter  in  the 
making  of  a  will  to  his  or  her  advantage  and  to  the  disadvantage 
of  others  who  may  have  as  great  or  even  greater  claim  upon  the 
testator's  bounty.  Not  infrequently  it  is  a  servant,  attendant, 
or  nurse  who  thus  intrenches  himself.  Sometimes  a  clever  and 
designing  woman,  taking  advantage  of  the  intimacy  existing 
between  nurse  and  patient,  so  plays  upon  the  mental  weakness 
of  the  latter  as  to  bring  about  the  making  of  a  will  in  which 
she  is  a  beneficiary,  perhaps  the  chief  beneficiary.  Not  infre- 
quently the  intrigue  succeeds  the  more  readily  when,  as  is 
frequently  the  case  in  aged  men,  the  patient  is  also  a  sufferer 
from  prostatic  disease.  Under  these  circumstances  there  is 
sometimes  a  remarkable  recrudescence  of  sexual  thoughts  and 
feelings.  Sexual  recrudescence  in  old  age  is  of  course  always 
pathologic,  but  under  its  influence  an  old  man  may  fall  in  love, 
and  may  fall  hopelessly  and  helplessly  under  the  influence  of 
the  woman  who  is  the  object  of  his  affection,  whom  he  may 
marry,  and  to  whom  he  may  bequeath  the  bulk  of  his  estate, 
leaving  httle  or  nothing,  it  may  be,  to  his  children. 

During  the  time  that  the  patient  is  in  this  condition,  delu- 
sions may  manifest  themselves.  Among  these  are  expansive 
delusions  as  to  the  physical  health  and  \igor  of  the  patient, 
and  also  persecutory  delusions  as  to  ill-treatment  and  abuse 
by  children  or  other  relatives  who  very  naturally  oppose  his 
marrying.  That  under  such  circmnstances  serious  trouble 
and  unhappiness  occurs  in  famihes,  that  improper  and  imjust 
wills  are  made,  and  that  subsequent  contests  arise  in  the  courts 
is  a  not  unfamiliar  story.  At  times  the  above  picture  is  com- 
pUcated  by  confusion;  the  bladder  frequently  becomes  in- 
fected from  repeated  catheterization,  or  there  may  be  involve- 


MENTAL    DISEASES    AS    RELATED    TO    AGE  349 

ment  of  the  kidneys,  and  the  patient  becomes,  in  his  ah-eady 
weakened  state,  also  toxic  and  hallucinatory. 

The  fact  that  the  patient,  after  erotic,  persecutory,  or  ex- 
pansive delusions  have  made  their  appearance,  continues  for  a 
long  time  to  perform  acts  that  he  has  been  in  the  habit  of  per- 
forming many  times  and  for  many  years,  is  sometimes  cited 
as  proof  of  his  sanity.  As  a  matter  of  fact,  an  aged  man 
may,  under  these  circumstances,  continue  to  sign  and  endorse 
checks,  may  subscribe  his  name  to  other  papers,  give  accus- 
tomed directions,  play  cards,  checkers,  or  other  games,  and 
thus  present  a  superficial  appearance  of  mental  integrity.  At 
the  same  time,  just  such  a  patient  may  be  unaware  that  he 
has  broken  wind,  has  urinated  on  the  floor,  or  defecated 
ii^o  his  clothes. 

Occasionally  cases  of  senile  dementia  with  prostatic  disease 
manifest  eroticism  and  sexual  recrudescence  in  other  ways  than 
by  love  affairs,  proposals,  and  marriage.  Sometimes  a  man 
previously  respectable  and  of  irreproachable  character  begins 
to  consort  with  lewd  women,  to  practise  exhibitionism,  to  toy 
with  children,  or  even  to  attempt  rape.  Usually  the  mental 
examination  reveals  senile  stigmata  more  or  less  pronounced. 

Alzheimer's  Disease. — Kraepelin  has  given  this  name  to  a 
special  group  of  cases  described  by  Alzheimer.  The  affection 
is  characterized  by  a  slowly  developing  but  very  marked  mental 
deterioration  and  which  is  accompanied  by  symptoms  suggest- 
ing -an  organic  brain  disease.  The  dementia  is  progressive  over 
several  j^ears.  Loss  of  memory,  poverty  of  thought,  lack  of 
clearness  are  increasingly  evident.  The  patient  becomes  con- 
fused, cannot  make  himself  understood,  gives  away  his  belong- 
ings. He  is  restless,  becomes  garrulous,  mumbles  to  himself; 
may  sing,  laugh,  exhibit  automatic  movements;  becomes  incon- 
tinent.   He  understands  no  directions,  interprets  no  gestures. 


350  MENTAL    DISEASES 

recognizes  no  objects  and  is  unable  to  carry  out  any  orderly 
procedure.  His  speech  is  greatly  disturbed.  He  may  begin 
with  a  few  phrases  or  sentences  coherently,  but  soon  halts, 
repeats  words  and  syllables,  and  usually  ends  in  a  riieaningless 
gabble.  Finally,  he  becomes  quite  mute,  at  most  uttering  oc- 
casional words  or  senseless  syllables  under  excitement.  He 
becomes  unable  to  feed  himself  or  to  take  care  of  himself  in  any 
way.  He  places  in  his  mouth  whatever  is  put  in  his  hands.  His 
dementia  is  profound. 

Among  the  physical  signs  are  marked  general  weakness, 
spasticity  of  muscle's,  especially  in  the  legs,  a  shuffling,  uncertain 
gait.  Focal  brain  symptoms  are  not  present  unless  it  be  the 
aphasic  and  apractic  disturbances.  The  pupillary  reactions 
appear  to  be  diminished.  Several  of  Kraepelin's  patients  suf- 
fered from  isolated  epileptiform  seizures.  At  times  arterio- 
sclerosis is  present.  After  a  number  of  years  the  patients  finally 
succumb  to  intercurrent  disease. 

The  autopsy  reveals  changes  in  keeping  with  those  of  a  grave 
senile  dementia.  However,  the  necrotic  foci  seen  in  ordinary 
senile  dementia  are  here  very  numerous,  while  extensive  de- 
struction of  the  cortical  cells  is  everywhere  noted.  The  places 
of  the  latter  are  taken  by  bundles  of  fibrillar  The  latter  stain 
deeply  and  are  probably  the  remains  of  former  cell  bodies.  The 
glia  shows  extensive  proliferation,  especially  around  the  necrotic 
foci.  The  latter  are  filled,  as  in  senile  dementia,  with  a  colorless 
material  probably  the  result  of  nerve  substance  destruction. 

The  clinical  picture  suggests  that  in  Alzheimer's  disease  we 
have  to  deal  with  an  especially  severe  form  of  senile  dementia. 
The  fact  that  it  may  begin  relatively  early,  for  instance,  before 
fifty  years  of  age,  points  to  a  precocious  senile  dementia;  but 
possibly  a  special  pathological  process  independent  of  age 
is  at  work. 


MENTAL    DISEASES    AS    RELATED    TO    AGE  351 

Senile  Melancholia  and  Senile  Mania. — In  old  age  phases  of 
melancholia  may  make  their  appearance,  just  as  they  do  at. 
other  periods  of  life.  The  depression  is,  as  a  rule,  marked  and 
extremely  persistent;  it  differs  but  little  in  its  symptomatology 
from  that  of  the  melancholia  of  middle  life.  There  is  the  same 
hopelessness,  the  same  self-accusatory  attitude  of  mind,  the 
same  admixture  of  hypochondriacal  ideas.  Like  the  melan- 
cholia of  middle  life  again,  it  is  very  prolonged,  may  become 
chronic  or  may  terminate  in  dementia.  However,  now  and 
then  a  senile  melancholia  makes  a  good  recovery.  The  dif- 
ferential diagnosis  from  senile  dementia  becomes  therefore 
important.  This  is  to  be  based,  first,  upon  a  careful  and 
detailed  review  of  the  patient's  life,  in  order  to  determine 
the  presence  or  absence  of  manic-depressive  elements;  a 
history  of  a  previous  attack  of  depression  or  perhaps  of  ex- 
pansion is  of  the  utmost  importance.  Secondly,  in  the  exam- 
ination of  the  patient,  unmistakable  signs  of  actual  mental 
loss  should  be  carefully  sought  for.  Their  presence  in  a  degree 
strongly  favors  the  diagnosis  of  senile  dementia.  Because  of 
the  indifference  of  the  patient  and  his  not  infrequent  unwilling- 
ness to  talk,  much  time  and  patience  are  required. 

Senile  mania  is  quite  rare.  In  its  symptomatology,  it  does 
not  differ  from  that  presented  by  the  manic  phase  at  other 
periods  of  life.  It  is,  however,  much  more  prolonged  and,  like 
senile  melancholia,  does  not  offer  the  same  prospect  of  recovery. 


CHAPTER  III 

MENTAL  DISEASES  NOT  ORDINARILY  INCLUDED 
UNDER  INSANITY 

There  remains  to  be  considered  a  residue  of  mental  cases 
which,  though  not  classified  among  the  insane,  are  notwithstand- 
ing clearly  and  definitely  abnormal.  Every  community  contains 
a  number  of  individuals  who  make  up  its  proportion  of  defect- 
ives and  deviates.  Among  these  are  to  be  found  some  of  the 
unsuccessful,  the  misfits  of  society,  as  well  as  the  immoral,  the 
vicious,  and  the  criminal.  They  separate  themselves  into  two 
groups,  which,  though  quite  distinct,  may  merge  into  one 
another. 

BORDERLAND  MANIC  AND  PARANOID  STATES 

(The  Mattoids) 
Among  the  first  we  may  find  cases  clearly  related  to  the 
manic-depressive  group,  and  which  are  indeed  frequently  in- 
stances of  exceedingly  prolonged  hypomanic  states,  interrupted, 
it  may  be,  by  relatively  normal  periods  or  by  periods  of  depres- 
sion. At  other  times  the  mental  attitude  is  distinctly  paranoid. 
The  individual  often  presents  an  appearance  of  brilliancy  and 
originality,  but  with  this  he  betrays,  as  a  rule,  great  defects  of 
judgment  and  of  will-power.  His  mental  vision  is  rarely  clear; 
he  fails  to  see  things  in  their  proper  proportion  or  in  their  real 
relations  to  each  other.  Especially  does  he  fail  to  appreciate 
closely  or  adequately  his  own  relation  to  the  external  world,  to 
the  circumstances  in  which  he  is  placed,  and  to  the  conditions 
with  which  he  must  cope.     The  various  undertakings  in  which 

352 


DISEASES    NOT    ORDINARILY    INCLUDED    UNDER   INSANITY     353 

he  engages  are  badly  planned  and  doomed  to  failure.  He 
rarely  remains  long  enough  in  any  one  occupation  to  acquire  a 
thorough  knowledge  of  it.  He  changes  from  one  trade,  one 
employment,  one  calling  to  another.  He  lacks  the  persistence, 
the  strength  of  -^ill,  to  complete  or  carry  to  its  logical  conclusion 
a  given  undertaking.  Slight  obstacles  discourage  him  and  often 
lead  to  a  radical  change  of  plan.  At  the  same  time,  he  usually 
talks  a  great  deal,  is  often  addicted  to  monologue,  and  betrays, 
by  his  conversation  and  attitude,  that  he  has  an  expanded  per- 
sonality. He  manifests  little  or  no  feeling  for  others,  no  s\ttl- 
pathy  or  consideration.  He  is  self-absorbed,  vain,  egotistic, 
and  self-assertive.  Often  he  impresses  his  relatives  and  friends 
as  though  he  were  unusually  bright,  original,  and  capable. 
Sometimes  he  is  looked  upon  as  a  kind  of  genius.  Time,  how- 
ever, passes  and  no  results  are  achieved,  the  money  of  friends 
and  relatives  is  lost  in  this  or  that  enterprise.  Failure  is  the 
continual  outcome.  As  the  years  go  by,  a  misanthropic  atti- 
tude of  mind — a  paranoid  view  of  life,  the  idea  that  the  world 
is  against  him,  that  he  has  been  much  abused — makes  its  ap- 
pearance. Alcoholism  often  complicates  the  picture.  Indiffer- 
ence to  obhgations,  neglect  of  family  and  friends,  rank  dis- 
honesty are  usual  accompaniments.  To  he,  to  s'odndle,  to 
obtain  money  by  devious  paths  are  common  expedients. 

Few  of  those  who  come  into  casual  contact  with  such  an 
individual  reahze  his  true  condition.  The  latter  is  only  dis- 
closed by  a  painstaking  study  of  his  history.  As  a  rule,  the 
intimate  facts  can  only  be  elicited  from  those  who  have  had 
the  misfortune  to  live  with  him.  Quite  cormnonly  even  his 
family  scout  the  idea  of  his  not  being  mentally  well;  perhaps 
it  is  a  single  one,  a  long  suffering  mother  or  father,  who  takes 
the  opposite  view.  That  he  is  held  strictly  accountable  to  the 
law  is  of  course  well  kno\sTi. 

23 


354  MENTAL    DISEASES 

That  hereditary  neuropathic  factors  are  present  in  such 
cases  need  hardly  be  added.  The  mental  examination  reveals 
nothing  that  is  clinically  significant.  The  inteUigence  is 
average,  sometimes  decidedly  above  the  usual  level;  there  are 
no  well-defined  delusions,  no  hallucinations.  Manic  or  para- 
noid factors,  however,  are  revealed  either  in  the  history,  as 
already  pointed  out,  or  in  the  course  of  the  examination. 

STATES  OF  HIGH-GRADE  DEFICIENCY;  MORAL  DEFICIENCY; 

CRIMINALITY 

(The  Morons) 

In  considering  arrested  development  in  children,  it  was 
pointed  out  that  the  arrest  might  be  general  in  character,  in- 
volving all  of  the  mental  faculties,  or  that  the  arrest  might  be 
quite  unequal  and  irregular.  If  the  arrest  of  development  be 
relatively  slight,  and  at  the  same  time  general,  an  individual 
results  who  is  less  capable,  less  fitted  for  the  struggle  of  exist- 
ence than  his  fellows,  but  who  does  not  differ  from  them  ma- 
terially in  his  conduct  or  in  his  relations  to  society.  If  there 
be  a  lessened  intelligence  but  a  preservation  of  the  feelings,  of 
the  normal  emotional  reactions,  the  individual  may  be  an 
inefficient  but  a  well-behaved  member  of  the  community. 
Unfortunately,  however,  the  condition  most  frequently  met 
with  is  one  in  which  the  intelligence  is  fairly  well  preserved — 
at  least  reveals  no  deterioration  to  ordinary  examination — but 
in  which  there  are  marked  disorders  of  feeling,  of  will,  and  of 
character.  There  is  an  absence  of  the  feeling  for  others  which 
normally  expresses  itself  in  sympathy  and  altruism;  there  is 
an  absence  of  the  conception  of  suffering  or  pain  in  others  and 
an  inability  to  take  in  moral  or  ethical  ideas  generally. 

As  children,  such  individuals  are  egotistic,  self-willed,  stub- 
bom   and  callous.      They  are  undemonstrative   toward  their 


DISEASES    NOT    ORDINARILY    INCLUDED    UNDER    INSANITY     355 

parents,  and  indeed  evince  a  dislike  of  being  caressed.  To 
have  their  own  way,  to  disobey,  is  almost  instinctive.  They 
are  indifferent  alike  to  scolding  or  to  praise.  The  sorrow  which 
their  parents  may  have  because  of  their  conduct  makes  no  im- 
pression upon  them.  They  lie,  resist  control,  and,  when  the  at- 
tempt is  made  to  coerce  them,  sometimes  do  the  exact  opposite 
of  what  they  are  bidden  to  do.  They  are  easily  angered,  have 
violent  tempers,  are  jealous,  vindictive,  and  cruel.  Quite  often 
they  evince  a  fondness  for  torturing  animals  and  for  maltreating 
their  smaller  playmates.  At  school  they  are  lazy,  make  no  prog- 
ress, resent  discipline,  commit  mischief,  disorganize  the  order 
of  the  classroom.  Soon  they  become  incorrigibles;  sometimes 
a  gross  infraction  of  the  peace  leads  to  the  reformatory,  correc- 
tion, or  other  institution;  at  other  times,  they  run  away  from 
home  and  live  by  begging  and  theft;  they  may  travel  alone  or 
may  associate  themselves  with  tramps  and  criminals.  Often 
they  return  home  after  a  longer  or  shorter  period  of  vagabondage, 
make  no  explanation,  or  tell  impossible  stories,  invent  self- 
evident  lies,  take  their  punishment  without  a  murmur,  and, 
after  an  interval,  may  repeat  the  escapade.  Frequently  the 
absences  grow  longer,  and  sometimes  the  child  or  youth  dis- 
appears definitely.    _ 

In  children  of  this  kind,  the  sexual  instinct  is,  as  a  rule,  pre- 
cociously developed.  They  masturbate,  practice  perversions, 
mislead  other  boys,  commit  assaults  on  little  children.  Some- 
times these  traits  appear  before  puberty;  if  so  they  become 
accentuated  at  this  period. 

In  some  cases  the  tendency  to  wander  does  not  make  itself 
evident  until  adult  life  is  reached.  Then  restlessness,  an  un- 
stable mood,  an  impulse  for  change,  drives  the  individual  from 
place  to  place;  he  roams  through  the  country  or  goes  by  train 
from  city  to  city,  from  one  distant  place  to  another.     Being 


356  MENTAL    DISEASES 

without  funds,  he  resorts  to  all  sorts  of  expedients  to  raise 
money.  Occasionally  he  seeks  emplojTnent,  but  being  poorly 
prepared,  impractical,  and  essentially  dishonest,  he  meets  with 
failure.  More  frequently  he  resorts  to  forged  checks,  drafts 
upon  his  relations,  exploits  his  friends,  obtains  goods  under 
false  pretense,  which  he  immediately  sells,  usually  at  the  first 
available  price.  Every  possible  resource  is  exhausted.  At 
times  he  embarks  on  a  career  of  crime,  finds  associates  in  the 
slums  and  by-ways,  and  may  end  by  becoming  a  professional 
criminal;  indeed,  as  is  well-known,  he  may  devote  himself  to 
certain  lines  of  work  for  which  he  has  especial  aptitude,  may 
become  bunco-steerer,  pickpocket,  sneak-thief,  burglar;  he 
may  even  acquire  a  special  pride  in  his  skill  and  achievements. 
That  murder  may  be  included  in  the  list  of  his  crimes  is  well 
kno^\^l.  Sooner  or  later,  of  course,  he  is  entangled  in  the  meshes 
of  the  law. 

Sometimes,  in  one  of  his  early  escapades,  he  marries,  later 
perhaps  commits  bigamy,  or  he  consorts  with  prostitutes. 
Quite  commonly  he  gives  himself  up  to  gambhng,  alcoholism, 
and  debauch. 

Girls  happily  are  less  frequently  the  victims  of  this  disorder. 
However,  when  they  are  afflicted,  they  present  the  same  history 
of  lying,  disobedience,  and  incorrigibility  in  childhood,  manifest 
the  same  sexual  precocity,  and  may  early  fall  into  prostitution. 
At  other  times,  the  young  woman  as  she  grows  up  betrays 
inordinate  vanity  and  love  of  finery.  She,  too,  indulges  in 
escapades,  but  usually  in  the  company  of  young  men.  She 
has  risque  adventures,  creates  talk,  gossip,  scandal.  Perhaps 
her  affairs  culminate  in  a  runaway  marriage.  If  married,  she 
avoids  pregnancy,  commits  abortion,  or,  if  she  has  children, 
neglects,  abuses,  ill-treats  them.  She  has  an  utter  disregard 
of  the  husband's  means  or  interests  and  makes  life  impossible 


DISEASES   NOT    ORDINARILY    INCLUDED    UNDER    INSANITY     357 

by  her  extravagances.  Quite  commonly  her  desire  for  admira- 
tion leads  her  to  encourage  the  society  of  other  men.  Breaches 
of  the  moral  law  are  frequent;  divorce,  degradation,  the  natural 
result.  As  a  consequence  of  the  abuse  of  alcohol,  the  infection 
of  syphihs  and  general  unphysiologic  living,  both  men  and 
women  of  this  class  may  acquire  some  form  of  insanity  necessi- 
tating asylum  commitment;  mdeed,  this  is  a  not  infrequent 
outcome. 

The  sufferers  from  this  form  of  deficiency  do  not,  of  course, 
recognize  their  own  condition,  nor,  indeed,  is  the  true  state  of 
affairs  appreciated  by  the  family;  at  least  not  early  in  the  case. 
The  patient's  intelhgence  seems  to  the  lay  observer  to  be 
ordinary;  it  does  not  attract  special  attention.  However, 
examination  usually  shows  it  to  be  unequally  and  irregularly 
developed.  Every  lazy  and  incorrigible  child  should  be  sub- 
jected to  a  thorough  psychologic  examination;  e.  g.,  by  the 
Binet-Simon  System.  (See  Whipple,  loc.  cit.)  The  intelli- 
gence may  be  found  below  normal,  fair,  good,  or  even  unusual. 
It  is  safe  to  say,  however,  that  in  a  large  number,  say  about  one- 
third,  it  will  be  found  subnormal.  However,  whatever  the 
facts  ehcited  by  such  an  examination  are,  one  fact  remains, 
namely,  that  the  general  intelligence  is  preserved  out  of  pro- 
portion to  the  moral  sense.  The  child  cannot  and  does  not  feel 
morally.  Ideas  of  sin,  wrong,  and  crime  are  not  associated 
with  feehngs  of  pain,  nor  are  ideas  of  duty,  right,  obedience 
associated  with  feelings  of  pleasure.  The  child  has  no  sense, 
no  feeling  of  right  and  wTong.  It  is  in  this  respect  an  idiot, 
and  the  terms  "moral  idiocy,"  "moral  insanity,"  long  ago  used 
by  English  writers,  adequately  designate  its  condition.  The 
acts  of  the  patient  are  determined  exclusively  by  his  appetites 
or  by  the  temptations  of  the  moment.  He  may  be,  and  usually 
is,  sufficiently  intelligent  to  appreciate  the  consequences  of  his 


358  MENTAL    DISEASES 

acts,  but  this  does  not  deter  him  from  following  his  incHnations. 
Prison  discipHne  sometimes,  though  infrequently,  has  a  bene- 
cial  effect;  unfortunately,  as  is  well  known,  the  prisoner  often 
recurs,  as  soon  as  liberated,  to  his  old  mode  of  Ufe,  and  a  history 
of  repeated  commitments  is  quite  common.  Improvement 
seems  to  be  possible  in  only  a  hmited  number.  If  the  individual 
lives,  advancing  years  may  bring  some  amelioration;  desires 
are  less  keen,  temptations  less  alluring. 

That  a  large  number  of  criminals  present  physical  stigmata 
of  arrest  was  long  ago  pointed  out  by  Lombroso,  and,  though 
one  can  hardly  subscribe  fully  to  his  interpretation  of  their 
significance — as  such  signs  are  occasionally  found  in  otherwise 
normal  persons — enough  is  kno'^Ti  concerning  the  criminal's 
mental  make-up  to  justify  the  conclusion  that  he  is  subnormal 
and  de\aate  in  development.  Equally  well  known  is  the  fact 
that  he  is  conmionly  the  victim  of  a  vicious  heredity,  a  heredity 
in  which  crime,  bastardy,  insanity,  syphiUs,  and  alcoholism 
play  significant  roles. 

SEXUAL  ABNORMALITIES 
In  the  preceding  section  it  was  noted  that  high-grade  de- 
fectives frequently  present  precocious  development  of  the 
sexual  instinct,  which,  in  addition  to  masturbation,  may  mani- 
fest itself  in  various  forms  of  sexual  perversion.  It  is  not  sur- 
prising to  find  defectives  in  whom  the  sexual  factors  constitute 
the  principal  clinical  features.  There  is,  first,  in  the  great 
majority  of  cases,  a  pronounced  neuropathic  heredity;  second, 
there  is,  in  the  larger  number,  a  more  or  less  marked  mental  de- 
ficiency' which  sometimes  amounts  to  feeble-mindedness.  At 
times  the  mental  deficiency  is  not  pronounced,  but  in  such 
cases  the  characteristics  noted  in  the  neurasthenic-neuropathic 
constitution   are   observed.      (See   p.    182.)      Third,    the   pa- 


DISEASES    NOT    ORDINARILY    INCLUDED    UNDER    INSANITY     359 

tient  not  infrequently  bears  upon  his  person  the  stigmata  of  an 
aberrant  development. 

Sexual  abnormalities  separate  themselves  roughly  into  two 
groups :  first,  those  in  which  sexual  evolution  has  been  incom- 
plete, and,  second,  those  in  which  sexual  evolution  has  been 
aberrant  so  that  the  impulse  is  inverted  or  perverted. 

Every  physician  meets  with  male  patients  in  whom  there  is 
more  or  less  marked  deficiency  of  sexual  development,  impulse, 
and  power.  Sometimes  an  examination  reveals  that  the  penis 
and  testicles  are  unusually  small,  or  that  perhaps  one  or  both 
testicles  have  failed  to  descend.  The  hair  on  the  pubis  and  in 
the  axilla  is  apt  to  be  sparse;  frequently,  too,  this  is  true  of  the 
hair  upon  the  face.  The  skeleton,  musculature,  voice,  and 
maimer  also  suggest  immaturity  although  the  patient  is  of 
adult  age.  In  pronounced  cases  the  penis,  scrotum,  and  tes- 
ticles remain  infantile,  the  face  is  beardless,  the  voice  child- 
like, and  the  patient  presents  a  diffuse  deposit  of  fat,  like  that 
seen  in  pituitary  deficiency.  Doubtless,  here  testicular  and 
pituitary  deficiency  go  hand  in  hand. 

Among  the  more  distressing  sexual  defectives  are  men  in 
whom  the  sexual  organs  are  of  normal  appearance,  and  in  whom 
the  secondary  sexual  characteristics — beard,  voice,  frame,  and 
musculature — likewise  appear  to  be  fairly  developed,  but  in 
whom  the  sexual  life  is  feeble  and  short.  Sometimes  the 
sexual  impulse  and  power  are  both  entirely  lacking;  more  fre- 
quently the  patient  presents  a  history  of  fair  sexual  competence 
extending  over  a  few  years  and  then  premature  failure.  Quite 
commonly  such  patients  are  sterile  from  the  beginning,  but 
this  is  of  course  not  necessarily  the  case. 

In  women  similar  conditions  are  met  with,  and  they  vary 
from  those  in  whom  there  is  marked  failure  of  sexual  evolution 
to  those  in  whom  sexual  evolution  seems  to  approximate  the 


360  MENTAL    DISEASES 

normal.  In  the  former  there  may  be  a  history  of  non-appear- 
ance or  of  late  and  imperfect  appearance  of  menstruation. 
Quite  frequently  the  uterus  is  infantile,  the  vagina  cleft,  and 
the  external  genitalia  exceedingly  small;  pubic  and  axillary 
hair  may  be  deficient;  the  breasts  are  small,  the  hips,  shoulders, 
and  torso  generally  like  those  of  a  child.  On  the  other  hand,  the 
general  physical  appearance  may  reveal  nothing  abnormal 
and  yet  the  patient  may  lack  entirely  sexual  impulse;  she  may 
be  frigid,  unresponsive,  or  the  sexual  act  may  be  painful  and 
disgusting.  Like  the  corresponding  male  patient,  she  may 
react  for  a  while  and  then  pass  into  a  period  of  premature  invo- 
lution, a  premature  menopause.  Like  the  male  patient,  again, 
she  may  show  the  evidences  of  an  involvement  of  the  internal 
secretions. 

Both  men  and  women  of  this  group  may  display  a  well- 
marked  tendency  to  affection  for  the  opposite  sex;  frequently, 
however,  this  is  ideal  and  platonic.  Again,  a  rigid  examination 
reveals  that  they  are,  as  a  rule,  somewhat  subnormal  mentally; 
it  cannot  be  claimed,  however,  that  this  is  invariable. 

The  second  group  of  cases,  that  in  which  sexual  evolution 
has  been  aberrant,  presents  quite  commonly  morphologic 
peculiarities  as  well  as  abnormal  sexual  impulses.-  It  is  sub- 
divided into  two  groups,  first,  those  in  which  the  impulse  is 
inverted,  second,  those  in  which  it  is  perverted.  The  first 
includes  instances  of  homosexual  love;  i.  e.,  cases  in  which  the 
sexual  impulse  is  toward  the  same  sex  as  the  patient.  Quite 
frequently  it  is  found  that  the  man  who  falls  in  love  with  another 
man  presents  certain  physical  pecuUarities.  Although  it  may 
be  that  the  genitalia  are  normal,  or  apparently  normal,  the 
man  presents  many  of  the  anatomic  features  of  woman;  thus, 
the  pelvis  and  buttocks  may  be  female  in  type,  the  breasts  may 
be  unusually  developed,  the  face  beardless,  the  voice  feminine, 


DISEASES    NOT    ORDINAEILY    INCLUDED    UNDER    INSANITY     361 

the  gait  mincing.  As  a  rule,  such  persons  play  the  passive 
part  in  the  abnormal  congress.  If  the  person  be  a  woman  she 
is,  as  a  rule,  "mannish"  in  appearance;  strides,  stands,  talks 
like  a  man,  has  narrow  hips  and  peMs,  small  breasts,  and 
perhaps  an  unusual  amomit  of  hair  on  the  face.  Sometimes, 
indeed,  examination  reveals  an  enlarged  and  erectile  chtoris. 
Occasionally,  too,  a  condition  of  the  genitaha  is  fomid — an  im- 
perfect differentiation — suggesting  hermaphroditism.  On  the 
other  hand,  patients  are  met  "^dth,  in  both  male  and  female 
homosexuals,  in  which  the  genital  organs  and  the  secondary 
sexual  characteristics  alike  do  not  differ  from  the  normal,  and 
in  whom,  notwithstanding,  the  sexual  impulse  is  inverted. 
Such  persons  may,  however,  marry  and  bear  children,  and 
yet  have  desperate  love  affairs  -^ith,  and  abandon  their  fami- 
lies for,  some  person  of  the  same  sex.  In  such  cases  the  in- 
version of  the  instinct  is  usually  purely  nervous  and  psychic; 
however,  at  times,  physical  gratification  may  be  indulged  in. 
Again,  there  are  individuals  who  faU  in  love  at  one  time  with  a 
member  of  the  opposite  sex  and  at  another  with  a  member  of 
the  same  sex. 

Sexual  perA^ersion  manifests  itself  in  a  variety  of  ways;  e.  g., 
sexual  congress  between  human  beings  and  animals,  "bestial- 
ity," or  sexual  congress  hj  a  man  with  a  dead  body,  "necro- 
phily."  Sadism,  so-named  after  the  Count  de  Sade,  is  a  form  of 
perversion  in  which  the  male  inflicts  pain  and  suffering  upon  the 
female,  often  with  great  cruelty,  in  obtaining  for  himseff  sexual 
gratification.  Sometimes  the  act  is  one  of  indescribable  bar- 
barity; the  male  killing  his  Adctim,  mutilating  the  body,  cutting 
off  breasts  and  genitals,  and  perhaps  ending  with  cannibahsm. 

At  times  the  perversion  manifests  itself  as  masochism,  so 
termed  after  an  Austrian  writer,  Sacher-Masoch.  The  male 
insists  on  pain  being  inflicted  upon  himself.     He  begs  the 


362  MENTAL    DISEASES 

woman  to  beat  or  maltreat  him  in  various  ways;  this  either 
induces  an  erection,  and  the  act  ends  in  intercourse,  or  it  con- 
stitutes the  entire  sexual  act,  the  man  having  an  orgasm  and 
emission  just  as  the  pain  is  most  intense  and  apparently  most 
difficult  to  bear.  Such  persons  will  occasionally  arm  the  woman 
with  a  whip,  which  she  applies  to  the  nates,  scrotum,  or  penis; 
at  other  times  the  individual  will  lie  upon  the  floor  and  insist 
on  being  stamped  and  trodden  upon.  Sadism  and  mas- 
ochism are  innate  perversions;  in  some  cases  previous  sexual 
excesses  and  exhaustion  seem  to  play  a  r61e. 

Occasionally  it  is  some  part  of  the  apparel  of  the  female, 
a  slipper,  shoe,  skirt,  undergarment,  the  sight  or  handling  of 
which  leads  to  erection  and  ejaculation,  or,  it  may  be,  to  a 
paroxysm  of  masturbation.  Sometimes  it  is  a  fragment  of  a 
skirt,  a  lock  of  hair,  a  curl  or  plat,  which  the  patient  snips  off 
with  a  scissors;  quite  commonly,  too,  erections  and  orgasms 
occur  the  moment  the  desired  object  is  secured — the  moment 
that  the  scissors  cuts  through  the  dress  or  snips  the  curl.  When 
this  is  the  case,  the  fragment  of  dress  or  the  curl  is  thrown  away 
afterward;  otherwise  it  is  retained.  Exceedingly  disgusting 
forms  of  this  affection,  which  is  spoken  of  as  fetichism,  may  be 
met  with,  as  when  the  patient  preserves  or  cherishes  the  urine 
and  dejecta  of  the  female  or  actually  swallows  them.  Persons 
who  suffer  from  fetichism  not  infrequently  present  the  charac- 
teristics of  the  neurasthenic-neuropathic  make-up,  i.  e.,  of 
psychasthenia ;  and  their  perversion  has  its  origin  in  the  forma- 
tion of  pathologic  associations.  (See  Part  I,  Chap.  VI.)  The 
inherent  neuropathy  of  the  individual  is  always  the  cardinal 
factor. 

Sexual  precocity,  as  we  have  seen,  is  a  very  common  s\Tnptom 
in  defectives.  This  precocity  may  early  lead  to  various  forms 
of  perversion,  pederasty,  bestiality,  and  the  like,  or  masturba- 


DISEASES    NOT    ORDINARILY    INCLUDED    UNDER    INSANITY     363 

tion  and  other  excesses  may  result  in  sexual  exhaustion,  so 
that  extraordinary  stimuli  are  required  to  produce  sexual  grati- 
fication. This  is  probably,  as  already  stated,  the  explanation, 
in  part,  of  sadism  and  masochism. 

Sometimes  fetichism  manifests  itself  in  such  a  way  that  all 
the  patient  desires  is  a  sight  of  the  female  genitals  or  limbs, 
when  masturbation  results,  and  there  are  cases  in  which  the 
male,  having  actual  access  to  the  female,  masturbates  in  her 
presence  instead  of  having  intercourse. 

The  prognosis  of  sexual  perversion,  when  accompanied  by 
marked  morphologic  peculiarities,  is  of  course  unfavorable. 
When  it  occurs  in  neurasthenic-neuropathic  subjects,  or  when 
it  manifests  itself  only  as  an  occasional  symptom,  much  may 
at  times  be  accomplished  by  physiologic  living  accompanied 
by  physical  activity  leading  daily  to  normal  fatigue.  Sug- 
gestion and  other  forms  of  psychotherapy  should  of  course  be 
employed.     Hypnotism  is  of  doubtful  value. 

In  simple  sexual  deficiency  animal  extracts,   spermin,   or 

lutein  may  be  tried  over  a  long  period  of  time.     Occasionally 

the  chain  of  the  glands  of  internal  secretion  may  be  stimulated 

by  the  prolonged  administration  of  small  doses  of  thyroid 

extract. 

HYPOCHONDRIA 

Hypochondria,  though  far  removed  from  the  other  topics 
treated  in  this  chapter,  notwithstanding,  merits  here  both  a 
place  and  adequate  consideration.  It,  also,  is  a  borderland 
mental  state,  classifiable,  on  the  one  hand,  with  the  neuroses — 
neurasthenia,  psychasthenia,  and  hysteria^ — and,  on  the  other, 
frankly  with  mental  diseases.  Hippocrates  does  not  use  the 
term  "hypochondria."  Galen,  however,  speaks  of  morbus 
hypochondriacus;  later  writers  speak  of  hypochondriasis  and 
associate  the  conditions  with  complaints  of  the  stomach  and 


364  MENTAL    DISEASES 

of  digestion.  It  was  not,  however,  until  the  latter  part  of  the 
eighteenth  century  that  it  was  more  definitely  recognized. 
In  17G5  Robert  Whj^te,  of  Edinburgh,  in  his  treatise  on  the 
nervous,  hysteric,  and  hypochondriac  disorders,  clearly  sepa- 
rated it  from  the  other  two  affections.  He  says:  "The  com- 
plaints of  the  first  of  the  above  classes  may  be  called  simply 
nervous;  those  of  the  second,  in  compliance  with  custom,  may  be 
said  to  be  hysteric,  and  those  of  the  third,  hypochondriac." 
We  have  here  an  instance  of  remarkable  clarity  of  vision.  In 
the  middle  of  the  nineteenth  century  French  writers,  beginning 
with  Georget,  recognized  the  mental  character  of  the  symptoms. 
German  writers — Romberg,  Griesinger,  Schuele,  Mendel,  Jolly, 
and  many  others — followed.  Von  Hoesslin  was  one  of  the  first 
to  differentiate  it  clearly  from  the  latter  affection,  and  in  this 
he  was  followed  by  Mueller,  Bouveret,  and  others. 

Hypochondria  is  frequently  confounded,  on  the  one  hand, 
with  neurasthenia  and,  on  the  other,  with  melancholia ;  for  a  long 
time,  too,  it  was  confounded  with  hj^steria;  many  of  the  older 
writers  regarded  it  as  the  expression  of  this  disease  in  the  male. 
Further,  medical  writers  have  been  loath  to  grant  to  hypochon- 
dria a  definite  position  in  our  nosology  largely  for  the  reason 
that  hypochondriacal  phases  are  observed  in  various  mental 
affections  such  as  the  prodomal  periods  of  melancholia,  of  para- 
noia, and  in  various  demented  states.  However,  an  increasing 
clinical  knowledge  has  shown  that  hypochondria  occurs  inde- 
pendently of  these  affections;  further,  that  it  occurs  without 
the  presence  of  a  single  symptom  of  neurasthenia  or  of  a  single 
stigma  of  hysteria.  Its  sjTnptom  group  occurs  alone  and 
pursues  its  own  course.  It  is  the  expression  of  a  diseased  person- 
ality, of  an  abnormal  condition  inherent  in  the  individual. 
Its  symptoms  owe  their  origin  to  a  change  in  the  general  sense 


DISEASES    NOT    ORDINARILY    INCLUDED    UNDER    INSANITY     365 

of  bodily  well-being,  a  change  which  gives  rise  to  a  more  or  less 
fixed  conviction  of  illness. 

It  would  appear  that  all  of  the  various  changes  taking  place 
in  the  body,  all  of  the  somatic  processes  concerned  in  the  nutri- 
tion of  the  tissues  and  in  the  functions  of  the  various  organs, 
impress  themselves  to  a  greater  or  less  degree  upon  the  field  of 
consciousness.  The  sum  total  of  the  impressions  received  gives 
rise  to  states  of  bodily  feeling,  and  the  latter  directly  affect 
the  psychic  state  of  the  individual.  Normally,  the  somatic 
changes  do  not  impress  themselves  vividly  upon  the  field  of 
consciousness.  They  merely  give  rise  to  a  generalized  sense  of 
feeling  well.  Further,  it  is  the  sensations  evoked  by  the  stimuli 
received  from  the  external  world  through  the  various  sense 
organs  that  normally  dominate  the  field  of  consciousness, 
and  in  keeping  with  this  the  mental  attitude  of  the  individual 
is  objective.  In  hypochondria,  on  the  other  hand,  it  is  the 
somatic  impressions  which  dominate  the  field  of  consciousness; 
and  these  impressions  are  of  such  a  character  as  to  produce  a 
feeling  of  illness;  that  the  mental  attitude  is  subjective  under 
these  circumstances  need  hardly  be  added.  It  is  important  to 
point  out  further  that  actual  physical  disease  or  obvious  dis- 
orders of  function  are  not  present.  Owing  to  an  inherent  neu- 
ropathy in  the  individual,  the  somatic  impressions  evoke  sensa- 
tions that  are  pathological;  commonly  these  are  vague  and 
generaHzed;  at  times,  however,  they  are  quite  definite  and  ap- 
proach visceral  hallucinations  in  character. 

The  sense  of  illness,  of  not  being  well,  varies  greatly  in  degree 
in  different  cases.  Sometimes  it  is  comparatively  mild,  and  in 
such  instances  may  lead  merely  to  an  undue  amount  of  com- 
plaining. At  other  times  it  is  very  pronounced,  and  then  domi- 
nates the  life  and  actions  of  the  individual.  The  patient  usually 
explains  his  condition  by  disease  of  the  stomach,  bowels,  liver, 


366  MENTAL    DISEASES 

or  Other  organs.  His  belief  is  not  founded  upon  pain  or  other 
distressing  sensations  in  the  region  complained  of,  but  is  merely 
a  conclusion  based  upon  his  general  feeling  of  illness.  It  need 
hardly  be  added  that  the  most  careful  investigation  fails  to 
reveal  any  evidences  of  actual  organic  changes,  and  if  functional 
disturbances  are  present,  these  are  slight  and  inconsequential 
and  cannot  be  invoked  to  explain  the  mental  condition  of  the 
patient.  When  the  hypochondria  is  marked  or  profound,  it  may 
suggest  melancholia.  There  can,  however,  be  no  difficulty  in 
making  a  correct  diagnosis.  Melancholia  is  a  phase  of  manic- 
depressive  insanity,  it  has  a  wave-like  course,  is  characterized 
by  more  or  less  psychic  pain  together  with  ideas  of  self-accusa- 
tion which  are  commonly  expressed  in  terms  of  the  delusion  of 
the  unpardonable  sin.  In  other  words,  in  melancholia  the 
explanation  of  the  psychic  suffering  concerns  itself  with  sinful- 
ness, moral  un worthiness,  spiritual  ruin.  In  the  melancholia  of 
middle  life — the  so-called  melancholia  of  involution — it  is  true 
that  hj'pochondriacal  ideas  are  frequently  present,  but  in  such 
case  they  form  but  a  part,  usually  a  very  small  part,  of  the 
larger  picture  of  self-accusation  and  sinfulness.  In  hypo- 
chondria, on  the  other  hand,  the  ideas  of  the  patient  relate 
solely  to  conditions  of  the  bod3\  It  is  the  various  feelings  of  the 
bodj'  and  the  various  disorders  which  he  believes  to  exist  in  the 
body,  which  occupy  his  mind. 

As  might  be  expected,  hereditary  factors  are  quite  common 
in  hjTJochondria.  Xot  infrequently  we  receive  a  history  of  a 
similar  affection  in  the  father  or  other  ancestor.  Sometimes 
it  is  a  history  of  insanity  or  other  nerv^ous  affection.  Quite 
commonly  hereditarj^  neuropathic  factors  are  pronounced. 
Occasionally,  too,  a  brother  or  other  near  relative  suffers  like 
the  patient  or  has  a  history  of  nervousness  or  of  mental  disease. 

While  hj'pochondria  is  unquestionably  hereditary  and  innate. 


-  DISEASES    NOT    ORDINARILY    INCLUDED    UNDER    INSANITY     367 

its  development  is  favored  by  all  forms  of  unphysiological  living. 
Thus,  it  is  more  common  among  those  who  live  narrow  and 
restricted  lives;  for  example,  it  is  found  among  clerks,  students, 
and  professional  people  whose  lives  are  inactive  and  repressed. 
On  the  other  hand,  it  may  be  met  with  among  persons  who 
work  out  of  doors  and  who  earn  their  hving  by  physical  labor; 
for  example,  laborers  and  farm  hands.  Here  the  unfavorable 
influences  are  the  monotony  of  life  and  the  daily  sameness  of 
existence.  Again,  idleness,  the  want  of  occupation,  the  absence 
of  special  interests  or  objects  in  life  are  also  predisposing  causes. 
The  effect  of  idleness  is  sometimes  illustrated  in  a  striking  man- 
ner in  the  hypochondriasis  of  middle  life.  A  man  who  has 
pre^^ously  been  active  and  who  has  accumulated  means,  sud- 
denly abandons  himself  to  a  life  of  ease.  The  stimulus  of  work 
no  longer  entails  an  objective  attitude  of  mind.  Further,  he  no 
longer  eats  well  or  he  eats  too  much,  smokes  more  than  formerly, 
allows  himself  an  unaccustomed  amount  of  alcohol,  has  no 
exercise,  or  perhaps  plays  golf  to  the  point  of  overfatigue.  Soon 
he  is  not  well,  slight  disturbances  of  function,  such  as  an  atonic 
indigestion  or  constipation,  furnish  the  groundwork  of  a  noso- 
phobia. Before  long  he  becomes  the  victim  of  imaginary  ills 
and  may  gradually  develop  a  confirmed  hypochondria.  He 
begins  consulting  physicians,  changes  from  one  to  the  other, 
often  goes  from  one  city  to  another,  seeking  the  advice  of  this 
or  that  prominent  speciaHst,  or  he  extends  his  quest  by  going 
abroad.  Here  he  again  consults  physicians  and  ends  by  going 
from  one  well-kno"ViTa  health  resort  to  another.  Previous  to 
the  war  such  patients  made  veritable  pilgrimages  to  Carlsbad 
and  to  others  of  the  numerous  watering-places  and  cures  of 
Germany  and  Austria. 

Among  other  factors  favoring  the   development   of  hypo- 
chondria are  all  causes  which  depress  the  general  physiological 


368  MENTAL    DISEASES 

level,  such  as  the  abuse  of  alcohol  and  tobacco,  insufficient  or 
excessive  food,  physical  indulgence,  dissipation.  Occasionally 
suggestion  plays  a  role.  Thus,  it  is  seen  now  and  then  among 
medical  students  and  others  who  are  much  in  contact  with 
disease.  Sometimes  the  student  becomes  hypochondriacal  to 
the  extent  of  believing  himself  to  be  suffering  from  this  or  that 
disease  which  he  has  seen  in  the  clinics. 

It  is  clear,  let  us  repeat,  that  in  all  cases  of  hypochondria 
there  is  a  pre-existing  neuropathy,  a  ready  soil  for  the  develop- 
ment of  the  affection.  All  other  factors  have  merely  an  inciden- 
tal value. 

Premonitory  symptoms  of  a  later  appearing  hypochondria 
are  not  infrequently  noted  early  in  life.  Thus,  a  child  betrays 
unwonted  alarm  over  some  trifling  illness,  or  it  is  excessively 
frightened  or  reacts  inordinately  to  some  insignificant  hurt  or 
bruise.  In  keeping  with  this  is  the  fact  that  frequently  such  a 
child  will  not  begin  screaming  until  some  moments  have  elapsed 
after  an  injury  has  been  received;  that  is,  not  until  it  has  had 
time  to  realize  that  it  has  been  hurt.  It  is  not  the  physical  pain 
which  causes  the  reaction,  but  the  mental  make-up  of  the  child. 
The  tendency  to  hypochondria  is  sometimes  revealed  as  the 
child  grows  up,  sometimes  during  youth,  sometimes  as  youth 
merges  into  adult  Ufe.  The  individual  is  unusually  afraid  of 
illness,  is  physically  timorous,  inclined  to  nosophobia,  to  be 
concerned  about  his  health.  Later,  in  early  adult  life,  or, 
it  may  be,  in  more  mature  years,  the  symptoms  become  more 
pronounced.  Most  commonly  they  are  marked  before  forty; 
occasionally  they  do  not  reach  their  full  development  before 
middle  life  is  reached. 

It  should  be  added  that  hypochondria  is  more  common  among 
men,  although  some  of  the  most  pronounced  and  troublesome 
cases  that  have  come  under  the  observation  of  the  writer  have 


DISEASES    NOT    ORDINARILY    INCLUDED    UNDER    INSANITY    369 

occurred  in  women.  Finally,  hypochondria,  as  is  the  case  in 
so  many  other  mental  affections,  is  more  frequent  among  those 
who  are  unmarried. 

As  the  hypochondria  becomes  more  pronounced,  the  anxiety 
of  the  patient  about  his  health  increases.  He  may  be  constantly 
afraid  of  catching  cold,  of  acquiring  disease  of  the  chest  or 
abdomen.  Not  infrequently,  such  patients  come  to  the  phys- 
ician wearing  an  excessive  amount  of  clothing,  chest  protectors, 
abdominal  binders,  or  other  unnecessary  articles.  On  the  other 
hand,  his  fear  of  disease  of  the  stomach  or  bowels  may  lead  him 
to  adopt  a  special  dietary,  to  which,  however,  he  usually  adheres 
for  a  limited  time  only.  Thus,  he  may  adopt  an  exclusively 
vegetable  diet  or,  again,  a  diet  containing  an  excessive  amount 
of  meat.  More  frequently  it  is  a  special  class  of  foods  which 
is  affected  or  excluded.  At  one  time,  much  ado  is  made  over 
cereals,  breakfast  foods,  or  special  kinds  of  bread;  at  another, 
the  importance  of  this  or  that  fruit  at  breakfast  is  insisted  upon. 
Shortly  after,  these  very  articles  may  be  tabooed.  At  times, 
tea,  coffee,  or  alcoholic  stimulants  are  rigidly  excluded,  only  to 
be  resumed  later  on.  At  other  times,  water  is  taken  in  certain 
ways  or  in  fixed  quantities  at  definite  times.  Very  frequently, 
also,  the  patient  affects  the  various  table  waters;  first  one  and 
then  another  is  lauded  for  its  virtues. 

If  the  case  be  progressive,  or  if  the  case  be  more  pronounced 
and  confirmed,  the  vague  feelings  of  illness  may  give  way  to 
other  -sensations  that  are  more  definite,  and  which  later  on  may 
become  more  or  less  fixed.  The  patient  now  describes  various 
sensations,  which  he  refers  to  the  surface  of  the  body  or  to 
the  mucous  membranes.  Thus,  he  experiences  burning  sen- 
sations in  the  skin,  in  the  conjunctiva,  in  the  mucous  mem- 
brane of  the  mouth.  The  hair  upon  the  limbs  or  body  is  stiff, 
is  breaking  off,  is  falling  out;  the  skin  is  tight,  feels  cold,  or 

24 


370  MENTAL   DISEASES 

is  the  seat  of  creeping  sensations.  More  frequently  it  is  the 
digestive  tract  to  which  the  patient  refers  his  sensations; 
he  has  burning  sensations  in  the  stomach;  in  the  bowels,  the 
abdomen  feels  swollen,  or  he  has  strange  distressing  or  pain- 
ful sensations  in  the  genitals;  men  complain  of  pain  in  the 
testicles;  women,  of  burning  sensations  in  the  vulva  and  vagina. 
Sometimes  bizarre  sensations  are  complained  of,  referred  to 
this  or  that  part  of  the  body,  the  head,  the  trunk,  the  spine, 
which  the  patient  is  frequently  quite  unable  adequately  to 
describe.  Thus  he  complains  of  pressure  about  the  head; 
his  head  feels  as  though  there  were  an  iron  weight  pressing 
upon  the  top  or  iron  bands  about  the  temples  or  the  back 
of  the  head.  He  complains  of  pains  in  his  limbs;  the  limbs 
ache,  they  bum,  or  they  are  the  seat  of  fine  vibratory,  trembling, 
or  numb  sensations.  He  complains  frequently  of  backache 
and  of  pain  beneath  the  shoulder-blades.  He  has  distressing 
sensations  which  he  refers  to  the  hver  or  to  his  kidneys.  He 
complains  of  palpitation  of  the  heart,  of  pulsating  sensations 
in  the  epigastrium  or  in  the  abdomen.  One  of  my  patients 
had  one  of  his  testicles  removed  because  he  declared  it  pained 
him  beyond  endurance.  The  treatment,  however,  was  inef- 
fectual, as  the  pain  at  once  appeared  in  the  remaining  testicle. 
Wollenberg  cites  a  case  in  which  the  patient,  faihng  to  induce 
his  physicians  to  perform  castration,  himself  removed  one  of 
his  testicles  with  a  razor. 

An  examination  of  the  patient  fails  to  reveal  any  physical 
signs  of  moment,  though  now  and  then  he  is  deUcate  and  neurotic 
in  appearance.  As  often,  however,  his  physical  development 
is  fine;  he  is  large  of  Hmb  and  great  of  stature,  and  his  appear- 
ance is  in  crass  contradiction  with  the  grave  illness  of  which  he 
complains.  Not  infrequently,  too,  the  muscles  are  well  developed 
and  the  muscular  strength  is  fully  up  to  normal.     There  is  no 


DISEASES   NOT   OEDINARILY   INCLUDED   UNDER   INSANITY      371 

change  in  the  reflexes,  in  the  pupillary  reactions,  nor  in  any  of  the 
movements  executed  by  the  patient.  There  are,  very  infre- 
quently, a  coated  tongue  and  some  evidences  of  gastro-intestinal 
atony  and  catarrh,  together  with  constipation;  these  symptoms 
may,  however,  be  but  slightly,  if  at  all,  marked.  Not  infre- 
quently slight  catarrh  of  the  head  and  of  the  throat  is  noted,  and 
when  a  knowledge  of  such  a  catarrh  is  possessed  by  the  jpatient  it 
becomes  a  fruitful  source  of  hypochondriac  ideas.  The  patient, 
for  instance,  may  believe  that  he  is  developing  consumption 
or  other  frightful  and  serious  disease  from  which  he  will  never 
recover.  More  frequently  he  founds,  upon  slight  gastric 
catarrh  and  constipation,  a  belief  of  serious  disease  of  the  stom- 
ach or  bowels.  Beyond  the  indigestion  and  constipation  no 
other  visceral  or  somatic  sign  can,  as  a  rule,  be  detected.  Now 
and  then  a  coldness  of  the  hands  and  feet,  or  slight  lividity  of 
the  surface  or  other  evidence  of  feebleness  of  the  peripheral 
circulation,  is  noticed.  Most  frequently  an  elaborate  exami- 
nation of  the  blood,  urine,  stomach  contents,  and  feces 
reveals  absolutely  nothing.  The  mental  examination  also 
results  negatively,  as  a  rule,  in  so  far  as  the  general  intelli- 
gence is  concerned;  exceptionally  the  latter  is  distinctly  sub- 
normal. 

True  to  his  fear  of  being  ill,  the  hypochondriac  patient 
constantly  observes  his  functions.  Atonic  indigestion  and 
constipation  offer  him  abundant  opportunity.  He  may  note 
carefully  the  character  of  the  bowel  movements,  observing 
the  most  minute  details  with  regard  to  the  form,  size,  color, 
etc.,  of  the  evacuations.  Less  frequently  he  observes  the  urine. 
Now  and  then,  however,  if  it  be  phosphatic,  it  is  in  turn  care- 
fully studied  and  becomes  a  fruitful  source  of  nosophobia,  the 
patient  not  infrequently  beheving  that  he  has  spermatorrhea. 

Very  often  hypochondriac  patients  keep  careful  records  of 
their  symptoms.     It  is  a  common  experience  to  have  them 


372  MENTAL    DISEASES 

enter  the  physician's  oflBce,  seat  themselves,  and  then  draw 
forth  Uttle  sUps  of  paper  on  which  they  have  noted  a  multi- 
pUcity  of  symptoms  usually  subjective,  always  trivial  and  un- 
important, and  generally  incapable  of  verification.  In  manner 
and  bearing  the  hjrpochondriac  suggests  a  person  gravely 
oppressed  by  illness.  He  frequently  presents  the  history  of 
having  visited  physician  after  physician  in  the  vain  attempt  to 
obtain  satisfaction  as  to  his  condition.  The  varjdng  diagnoses 
that  are  formed  from  time  to  time  are  all  carefully  noted  by  him, 
and  all  serve  to  convince  him  that  he  is  really  a  very  sick  man. 
Not  infrequently  he  delves  into  medical  books,  increases  his 
nosophobia,  and  subsequently  displays  a  superficial  knowledge 
of  medical  terms  in  speaking  of  his  case.  Later  on  he  begins 
to  make  his  own  diagnoses,  and  then  goes  to  this  or  that  phy- 
sician with  his  diagnosis  fully  prepared.  Finding  little  satis- 
faction, or  obtaining  little  relief  from  physicians,  he  not  in- 
frequently begins  to  treat  himself,  and  he  finds  in  the  numerous 
quack  and  patent  medicines  so  extensively  advertised  in  this 
country  a  rich  field  for  the  gratification  of  his  nosophobia. 
Bottle  after  bottle  is  consumed,  first  of  this  and  then  of  that 
nostrum.  Pills,  powders,  Hniments,  and  salves  follow  in  their 
turn,  and  the  mantle  and  closets  of  his  rooms  are  not  infre- 
quently laden  with  empty  or  half-empty  bottles  and  boxes. 
One  of  the  features  of  marked  hypochondria  is  that  the  patient 
is  always  taking  medicine  of  some  kind  or  other;  it  may  be  a 
tonic,  a  laxative,  or  some  drug.  His  diagnoses  vary  from  week 
to  week  or  often  from  day  to  day.  To-day  he  has  disease  of 
the  stomach,  to-morrow  disease  of  the  fiver;  upon  another 
occasion,  it  is  disease  of  the  kidneys,  or  of  all  of  these  organs 
combined.  Slight  palpitation  of  the  heart  convinces  him  that 
he  has  fatal  heart  disease;  a  pulsating  sensation  in  the  epigas- 
triimi  convinces  him  that  he  has  an  aneurysm. 


DISEASES    NOT    ORDINARILY    INCLUDED    UNDER   INSANITY     373 

It  is  noticeable,  as  already  stated,  that  such  patients  fre- 
quently present  an  appearance  of  health  not  at  all  in  keeping 
with  the  symptoms  of  which  they  complain.  Thus,  a  man  who 
beheves  that  he  has  serious  disease  of  the  stomach  or  liver  not 
infrequently  has  an  excellent  appetite  and  eats  with  evident 
comfort  and  enjoyment.  He  may  show  excellent  judgment  in 
the  selection  of  his  dishes,  and  may  even  be  an  epicure  in  his 
tastes.  He  more  frequently  eats  too  much  than  too  httle; 
indeed,  the  quantity  is  not  infrequently  excessive. 

Very  often  we  find  that  the  hypochondriac,  among  other 
things,  has  extreme  views  or  extreme  habits  as  regards  physical 
exercise.  He  has  read,  perhaps,  that  physical  exercise  is 
necessary  to  health,  and  he  now  begins  to  devote  himself  to 
this  method  of  treatment.  One  system  of  exercise  after  another 
is  taken  up,  and,  for  a  time,  he  may  exercise  excessively. 
Long  walks  may  be  taken  or  fatiguing  runs  on  the  bicycle. 
Most  frequently  he  is  devoted  to  room  exercises,  and  he  buys 
apparatus  of  various  kinds,  which,  after  a  few  weeks  of  desul- 
tory use,  are  allowed  to  become  covered  with  dust.  Extreme 
forms  or  odd  forms  of  exercise,  respiratory  gymnastics,  etc., 
are  affected  by  him.  At  other  times  he  takes  grossly  insuffi- 
cient exercise,  is  fearful  of  the  slightest  exertion,  may  lie  down 
for  many  hours  of  the  day,  or,  believing  himself  to  be  ill,  may 
actually  go  to  bed. 

Often  he  entertains  absurd  views  in  regard  to  ventilation, 
sleeping  next  to  open  windows,  or,  on  the  other  hand,  admitting 
an  insufficient  amount  of  air  into  his  room.  Equally  absurd 
may  be  his  habits  as  to  bathing.  Frequently  he  bathes  ex- 
cessively. Every  form  of  douche,  spray,  shower,  steam  or 
hot-air  bath  is  tried;  or  he  bathes  in  cold,  in  hot  water,  daily 
insists  upon  his  plunges,  or,  sad  to  relate,  very  frequently  mani- 
fests an  excessive  fear  of  water  and  does  not  bathe  at  all.     No 


374  MENTAL   DISEASES 

procedure  is  too  absurd,  too  inconvenient,  or  too  unpleasant 
for  him  to  adopt.  Anj'  passing  fad  for  the  time  being  satisfies 
his  longing  for  treatment.  To-day  it  is  some  new  form  of 
exercise,  but  to-morrow  it  is  bowel  irrigation,  and  he  now 
becomes  a  disciple  of  the  high  enema. 

The  onset  of  hj^pochondria  is,  as  we  have  indicated,  extremely 
gradual  and  its  course  essentially  chronic.  Occasionally  its 
evolution  is  hurried  by  some  intercurrent  illness,  such  as  attacks 
of  acute  indigestion  or  perhaps  acute  febrile  affections.  As  a 
rule,  it  pursues  a  course  extending  over  many  years.  It  does 
not,  however,  usually  pursue  an  even  course.  Its  symptoms 
are  at  times  more  pronounced  and  at  times  less  pronounced. 
Indeed,  they  may  disappear  altogether  for  a  period,  a  true 
remission  setting  in,  which  persists  for  months  or  years. 
Later,  the  sjonptoms  may  recur  and  the  patient  may  pass 
through  another  hypochondriacal  period.  In  other  cases, 
again,  a  permanent  recovery  may  take  place,  no  recurrence 
ever  being  manifested.  In  many  cases  also  the  hypochondria 
fades  with  increasing  j'^ears  and  ultimately  disappears;  espe- 
cially is  this  the  case  with  the  hj^Dochondria  that  has  its  in- 
ception in  youth  and  early  adult  life. 

In  cases  in  which  hj^pochondria  is  progressive,  the  bodily 
nutrition  little  by  little  begins  to  suffer.  The  patient  grows 
thin,  gray,  and  sallow,  and  the  skin  and  mucous  membranes 
become  dry.  He  no  longer  sweats  readily.  The  bowel  move- 
ments are  dry.  Constipation  becomes  more  marked  than  ever, 
and  often  there  are  excessive  discharges  of  mucus.  His  ideas 
are  now  exclusively  concerned  with  himself.  The  condition 
of  his  hver  and  his  bowels  are  the  principle  topic  of  his  conver- 
sation. The  taking  of  pills  or  the  use  of  injections  constitute 
the  all-important  business  of  his  life.  In  such  cases,  it  need 
hardly  be  added,  the  hope  of  definitely  and  permanently  infiu- 


DISEASES    NOT    ORDINAEILY   INCLUDED    UNDER    INSANITY     375 

encing  the  patient's  condition  becomes  progressively  less  and 
less. 

Finally,  a  word  remains  to  be  said  concerning  the  general 
mental  make-up  of  the  hypochondriac.  This  may  be  distinctly 
subnormal,  though  not  necessarily  so.  Indeed,  the  patient 
may  be  somewhat  talented  or  may  manifest  ability  in  certain 
directions.  It  is  characteristic  of  the  hypochondriac,  however, 
that  he  lacks  the  ability  or  energy  to  finish  work  that  he  has 
begun.  Notwithstanding,  such  persons  may  in  their  early 
lives  be  quite  successful;  it  is  only  with  the  increasing 
hypochondria  that  they  become  incapables.  Again,  neither 
intellectual  development  nor  education  have  anything  to  do 
with  hypochondria,  for,  as  pointed  out,  the  latter  occurs  alike 
among  laborers  and  scholars.  Finally,  and  this  is  clinically 
important,  hypochondria  is  the  least  frequent  of  the  neuroses, 
and  it  is  probably  for  this  reason  that  it  often  remains  unrecog- 
nized or  is  mistaken  for  some  other  affection. 

While  hypochondria  usually  presents  itself  in  the  generaUzed 
form  above  described,  it  not  infrequently  assumes  a  special 
form;  that  is,  the  clinical  picture  is  dominated  by  a  special 
set  of  symptoms.  The  two  special  forms  most  familiar  to  the 
practitioner  are  respectively  the  gastro-intestinal  and  the  sexual 
form.  In  the  gastro-intestinal  form  the  patient  complains  of 
various  vague  and  distressing  sensations  referred  to  the  abdo- 
men or  to  the  digestive  tract,  and,  while  there  is  usually  present 
some  atonic  indigestion,  perhaps  also  slight  gastric  catarrh' 
and  constipation,  the  statements  of  the  patient  as  to  his  suffer- 
ings are  out  of  all  proportion  to  the  symptoms.  He  observes 
himself  most  closely.  A  slightly  coated  tongue  or  a  fancied  or 
unusual  feature  of  the  bowel  movements  alarm  him,  while 
shght  indigestion  may  be  accompanied  by  great  sinking  sensa- 
tions and  sudden  fright.     These  patients  are  the  ones  who  adopt 


376  MENTAL  DISEASES 

extreme  diets  or  curious  rules  as  to  eating,  who  exhaust  the  list 
of  laxatives,  and  who  find  great  satisfaction  in  the  use  of  in- 
jections, kneading  of  the  abdomen,  special  exercises,  etc.,  and 
who,  in  their  zeal  for  each  newly  discovered  dietary,  medicine, 
or  procedure,  advocate  and  extol  the  same  among  their  friends 
and  acquaintances. 

The  sexual  form  of  hypochondria  is  one  of  the  most  common 
forms  met  with,  so  common,  indeed,  as  not  to  merit  a  detailed 
description.  Its  victims  frequently  believe  themselves  to  be 
impotent.  Quite  commonly  they  are  young  men  who  have 
never  attempted  the  sexual  act;  not  infrequently  they  are 
engaged  to  be  married.  As  a  rule,  when  marriage  takes  place, 
they  prove  to  be  entirely  competent.  Every  now  and  then, 
however,  this  is  not  the  case,  the  fear,  nervousness,  and  espe- 
cially the  belief  that  impotence  exists  lead  to  failure.  The 
sexual  organs  are,  it  is  urmecessary  to  say,  perfectly  normal  to 
physical  examination.  Such  cases  are  correctly  classified  as 
cases  of  "psychic"  impotence.  Sexual  hypochondria  is  more 
common  in  early  youth,  and  not  infrequently  the  belief  in  sexual 
deficiency  or  impotence  is  based  upon  a  previous  masturbation, 
even  when  the  latter  has  been  sUght  and  insignificant.  Quite 
commonly  the  occurrence  of  seminal  emissions  forms  the  nu- 
cleus around  which  the  hypochondria  centers.  This  is  equally 
the  case  whether  the  emissions  are  excessive  or  whether  they 
are  merely  normal  in  their  frequency. 


CHAPTER  IV 

INSANITY  BY  CONTAGION 

In  considering  mystic  paranoia,  we  had  occasion  to  refer  to 
the  fact  that  the  patient  sometimes  imposes  his  delusions  upon 
large  numbers  of  other  and  apparently  sound  persons.  (See  p. 
157.)  In  a  similar  way  hysteria  is  contagious,  and  there  are 
numerous  instances  afforded  by  history  of  epidemics  of  hysteria 
— of  "demoniac  possession" — occurring  in  Europe  during  and 
subsequent  to  the  middle  ages.  Often  mysticism  and  hysteria 
are  commingled  in  these  epidemics,  which  still  occur  in  Russia 
in  our  own  day.  Every  now  and  then  physicians  observe  the 
contagiousness  of  hysteria  in  their  patients.  Sometimes  epi- 
demics appear  in  schools;  a  little  girl  is  attacked  by  hysteria, 
and  soon  others— perhaps  a  large  number— are  similarly 
affected. 

Contagion,  however,  presents  itself  in  a  more  concrete  form, 
and,  though  it  is  not  common,  it  occurs  with  sufficient  fre- 
quency to  demand  a  brief  consideration.  The  following  in- 
stances are  met  with:  first,  cases  in  which  a  single  delusive 
idea  or  notion  is  imposed  by  a  patient  on  a  person  who  is  well; 
second,  cases  in  which  a  series  of  delusions  sj^stematized  in 
character  are  thus  imposed;  third,  instances  in  which  two  or 
more  persons  become  insane  simultaneously;  fourth,  cases  in 
which  one  insane  person  imposes  his  delusions  upon  another 
insane  person;  fifth,  cases  in  which  there  is  a  transmission  of 
states  of  depression  and  excitement;  and,  finally,  cases  in  which 

a  person — e.  g.,  a  relative  or  a  nurse — inclose  contact  with  an 

377 


378  MENTAL    DISEASES 

insane  patient  becomes  insane  himself  without,  however,  ac- 
quiring the  mental  symptoms  of  the  patient. 

A  brief  consideration  of  the  subject  reveals  that  it  is  more 
complex  than  at  first  sight  appears.  Two  important  factors 
are  at  work.  First,  there  is  always  a  predisposition  on  the  part 
of  the  person  who  is  the  subject  of  the  contagion.  Such  pre- 
disposition is  usually  assured  by  the  fact  that  in  by  far  the  larger 
nimiber  of  instances  both  the  original  patient  and  the  one 
secondarily  affected  are  members  of  the  same  family;  indeed, 
frequently  they  are  sisters.  They  are  victims  of  the  same 
heredity  and  commonly  of  the  same  environment.  Second,  it 
is  necessary  that  the  person  who  is  the  victim  of  the  contagion 
should  present  a  certain  degree  of  vulnerability  to  suggestion. 
Such  a  vulnerability  is  part  and  parcel  of  the  heredity;  again 
the  secondary  patient  is  relatively  weaker  and  less  forceful 
than  the  original  patient,  and  usually  offers  little  if  any  re- 
sistance to  the  ideas  imposed.  When  the  two  patients  are  not 
related,  the  secondary  patient  is  always  feeble  and  degenerate 
and  lacking  in  individuality.  It  can  be  safely  maintained  that 
insanity  cannot  be  imposed  by  contagion  upon  a  sound  mind. 
The  historic  instances  of  great  hysteric  and  mystic  epidemics 
do  not,  of  course,  apply  here. 

The  character  of  the  contagion  varies  greatly.  We  have 
first  those  milder  instances,  in  which  merely  a  delusive  idea  or 
attitude  is  transmitted  to  the  second  party,  but  in  which  the 
facts  do  not  justify  the  diagnosis  of  a  communicated  insanity. 
For  example,  a  workman  in  the  early  period  of  the  depressive 
phase  of  a  paranoia  returns  to  his  home  in  the  evenings  com- 
plaining of  unfair  treatment  on  the  part  of  his  employer,  or 
of  abuse  on  the  part  of  his  fellow-employees.  He  will  probably 
have  the  sympathy  and  perhaps  active  support  of  his  wife  and 
children.     It  is  only  later,  when  the  mental  disease  becomes 


INSANITY    BY    CONTAGION  379 

evident  and  pronounced,  that  the  family  ceases  to  share  the 
patient's  attitude.  A  far  more  serious  instance  is  that  in  which 
a  friend,  frequently  not  a  relative,  acquires  the  notion  that  a 
patient  is  really  not  insane  and  has  been  improperly  committed. 
For  example,  a  woman  hears  that  a  friend  has  been  sent  to  an 
asylum,  visits  the  friend,  becomes  convinced  that  the  friend 
is  not  insane,  has  been  greatly  abused,  is  the  victim  of  ill- 
treatment  and  conspiracy,  and  has  been  wrongfully  committed. 
The  insanity  of  the  patient  may  be  so  pronounced  as  to  admit 
of  no  possible  doubt.  In  such  case  the  fact  of  insanity  may 
be  reluctantly  admitted  by  the  friend,  but  the  behef  in  ill- 
treatment  and  abuse  by  relatives,  doctors,  and  asylum  at- 
tendants may  be  adhered  to.  That,  under  such  circumstances, 
litigation,  attempts  at  rescue,  endless  trouble  and  annoyance 
to  both  relatives  and  physicians  may  be  caused,  is  well  known. 
Such  cases  are  not,  of  course,  true  instances  of  insanity  by 
contagion;  they  are,  however,  instances  in  which  at  least  the 
patient's  attitude  has  been  accepted  by  the  friend. 

Instances  of  true  contagion  are  met  with  in  cases  in  which  a 
group  of  delusional  ideas,  systematized  in  character,  are  trans- 
mitted from  a  patient  to  a  person  previously  well.  In  almost 
every  instance  the  patients  are  relatives;  most  frequently  they 
are  sisters  or  a  mother  and  daughter  who  have  lived  together 
in  close  intimacy.  Usually  the  form  of  insanity  presented  by 
the  primary  patient  is  that  of  a  simple  delusional  limacy. 
Quite  commonly  the  delusions  are  those  of  persecution  by  neigh- 
bors, by  the  authorities,  by  the  landlord.  Expansive  ideas 
may  also  make  their  appearance,  though  they  are  infrequent. 
The  second  patient  sooner  or  later  accepts  the  delusions  of  the 
sister  or  mother,  and  there  is  a  remarkable  uniformity  in  the 
general  conduct  and  attitude .     The  paranoia  thus  communicated 


380  MENTAL    DISEASES 

is  commonly  of  the  simple  non-hallucinatory  form;  if  hallucina- 
tions are  present  they  are  usually  not  transmitted  to  the  second 
patient;  their  reality,  however,  seems  to  be  accepted  by  the 
latter.  As  a  rule,  such  cases  result  in  commitment  only  when 
the  conduct  of  the  two  persons  has  in  some  outspoken  way 
attracted  the  attention  of  the  neighbors  or  of  the  authorities. 
Often  they  live  undisturbed  and  separated  from  the  world  for 
many  years.  For  a  long  time  they  are  known  only  for  their 
peculiarities,  aloofness,  and  isolation;  it  is  usually  when  they 
begin  making  absurd  complaints  and  charges  against  neighbors, 
shopkeepers,  and  others,  or  seek  redress  for  their  fancied  wrongs 
from  the  police,  that  they  come  under  observation.  Our 
knowledge  of  the  subject  is  largely  owing  to  the  French,  who 
have  applied  to  the  condition  the  very  expressive  term  of 
"folie  communiquee."  The  cases  are  quite  rare;  the  writer 
has  had  but  two  instances  under  his  own  observation;  both 
occurred  between  mother  and  daughter;  in  one  instance  only 
had  the  patients  been  committed  to  an  asylum. 

Occasionally  the  insanity  makes  its  appearance  simultane- 
ously, it  may  be  in  two  sisters,  or  it  may  be  two  brothers;  at 
least  it  is  impossible  to  fix  upon  one  or  the  other  as  the  original 
patient.  It  is  to  this  condition  that  the  term  "fohe  a  deux" 
is  especially  applicable.  Even  here,  however,  close  living 
together  and  isolation  seem  to  be  a  necessary  part  of  the  eti- 
ology, so  that  contagion  seems  here  also  to  play  a  role.  In  a 
remarkable  instance,  known  to  the  writer,  two  brothers,  twins, 
became  convinced  in  early  life  that  the  world  was  wicked  and 
insincere,  that  modem  civilization  was  altogether  wrong,  and 
that  men  could  not  be  good  and  honest  unless  they  returned 
to  a  primitive  form  of  life.  They,  therefore,  abandoned  a 
prosperous  hardware  business  in  which  they  had  been  engaged 
as  young  men,  retired  to  a  farm,  where  they  led  lives  of  great 


INSANITY    BY    CONTAGION  381 

eccentricity;  they  wore  almost  no  clothing,  working  about 
the  farm  in  a  condition  of  almost  complete  nudity;  they  allowed 
the  hair  and  beard  to  grow  without  hindrance,  lived  upon 
raw  and  boiled  vegetables,  and  led  lives  of  great  seclusion; 
although  when  they  met  strangers  they  did  not  hesitate  to 
expound  their  views.  Both  lived  to  a  rather  advanced  age; 
one  of  them  during  a  period  of  depression  attempted  suicide, 
and,  though  he  failed,  the  attempt  was  not  repeated.  The 
affection  from  which  they  suffered  was  evidently  a  paranoia 
simplex  (the  non-hallucinatory  form  of  paranoia)  occurring 
and  developing  simultaneously  in  twins. 

Instances  in  which  one  insane  patient  imposes  his  delusions 
upon  another  insane  patient  are  occasionally  observed  in  the 
asylums.  The  ideas  thus  communicated  are  always  paranoid, 
and,  as  in  other  instances  of  folie  communiquee,  it  is  the  more 
forceful  limatic  who  imposes  his  ideas  upon  his  weaker  neighbor. 
The  phenomenon  is  of  scientific  rather  than  of  practical  inter- 
est. As  a  rule  after  the  second  patient  has  been  separated 
from  the  first,  the  communicated  delusions  fade  and  disappear. 

A  case  of  melancholia  sometimes  communicates  his  depression 
to  another  person,  usually  a  relative;  frequently  the  patients 
are  sisters;  occasionally  they  are  husband  and  wife.  At  times 
a  common  suicide  is  arranged  and  may  even  be  carried  out. 
States  of  excitement  are  also  at  times  communicated;  especially 
may  this  be  the  case  if  religious  exaltation  be  present  in  the 
original  patient.  Conditions  closely  simulating  mania  may  thus 
be  communicated  from  one  person  to  another.  In  an  instance 
observed  at  the  Insane  Department  of  the  Philadelphia  Hos- 
pital some  years  ago  a  colored  woman,  suffering  apparently 
from  acute  mania,  infected  her  mother  and  her  sister.  Both 
of  the  secondary  patients,  the  mother  and  the  sister,  rapidly 
improved  upon  isolation,  the  original  case  running  a  somewhat 


382  MENTAL    DISEASES 

longer  course.  That  hysteric  excitement  may  be  thus  com- 
municated, we  have  already  seen. 

Instances  in  which  persons  who  nurse  or  attend  the  insane 
become  insane  themselves  are  relatively  rare.  It  is  very  in- 
frequent to  observe  a  mental  breakdown  in  an  asylum  at- 
tendant; notwithstanding  its  occurrence,  all  observers  will 
agree  as  to  its  rarity.  Somewhat  more  frequently  do  we  note 
such  a  breakdown  if  the  person  nursing  the  patient  happens  to 
be  a  mother  or  sister.  Here,  added  to  the  actual  strain  of  nurs- 
ing, loss  of  sleep,  and  confinement,  there  is  an  added  anxiety 
and  emotional  strain  often  most  difficult  to  bear.  Under  such 
circumstances  depression,  exhaustion  with  painful  confusion, 
may  finally  ensue  in  the  relative.  The  danger  is  the  greater 
because  the  sister,  for  example,  is  of  the  same  heredity  as  the 
patient  and  shares  with  the  latter  an  inherent  predisposition 
to  mental  disease. 

The  prognosis  of  communicated  insanity  depends,  of  course, 
upon  the  nature  and  degree  of  the  contamination.  Further, 
the  delusions  never  secure  the  same  firm  hold  on  the  secondary 
patient  as  upon  the  primary;  and,  in  the  majority  of  cases,  the 
secondary  patient  improves  and  finally  recovers  when  isolation 
is  instituted.  However,  now  and  then,  when  the  secondary 
patient  has  lived  for  many  years  with  the  original  patient,  and 
especially  if  this  period  has  covered  the  formative,  the  adoles- 
cent period  of  life,  as  in  the  case  of  a  daughter  living  vnth  a 
paranoid  mother,  the  daughter  may  cling  tenaciously  to  the 
delusions  that  she  has  acquired  from  the  mother  and,  indeed^ 
may  never  relinquish  them. 


PART   III 


CHAPTER  I 

THE    PSYCHOLOGIC    INTERPRETATION    OF    THE 
SYMPTOMS 

The  psychology  of  insanity  offers  an  interesting  and  inviting 
field  of  study.  The  object  of  the  present  volume,  however, 
which  is  that  of  a  purely  clinical  treatise,  limits  us  to  a  consider- 
ation of  the  essential  and  more  prominent  features  of  the  subject. 

We  have  defined  a  delusion  as  a  false  belief  concerning 
which  the  person  holding  it  is  incapable  of  accepting  evidence. 
A  systematized  delusive  belief  is  made  up  of  a  group  of 
associated  ideas.  Such  a  group  of  ideas  constitutes  a  com- 
plex. In  the  case  of  a  systematized  delusion,  the  complex  is 
of  course  pathologic.  It  need  not  be  stated  that  normal  com- 
plexes— i.  e.,  normal  beliefs — make  up  the  psychic  content  in 
health.  By  a  complex  is  meant  a  group  of  associated  ideas 
relating  to  a  given  subject.  Sometimes  such  a  complex  domi- 
nates the  mind  and  determines  both  the  point  of  view  and  the 
action  of  the  individual;  e.  g.,  a  statesman  entertains  a  group 
of  associated  ideas,  a  complex,  which  constitutes  his  political, 
belief  and  upon  which  he  bases  his  policy.  A  business  man 
entertains  a  complex  upon  which  he  bases  his  business  course 
or  enterprise;  a  chemist,  a  complex  upon  which  he  plans  his 
experiments  and  investigations.  The  persistence  or  strength 
of  a  complex  is  often  dependent  upon  the  degree  of  the  associated 
feeling  or  emotion.    Of  this  our  every-day  prejudices  are  striking 

383 


384  MENTAL   DISEASES 

examples.  The  complexes  which  a  young  man  in  love  enter- 
tains concerning  the  object  of  his  affection  constitute  another. 
A  pathologic  complex  differs  from  a  normal  complex  in  that  it 
is  inaccessible  to  other  and  conflicting  ideas,  no  matter  how 
insistently  the  latter  may  be  presented;  that  is,  the  delusion 
constitutes  a  system  by  itself;  between  it  and  other  groups 
of  ideas  there  is  a  break,  an  absence  of  association.  In  the 
familiar  instance  of  paranoia  such  a  system  dominates  the 
field  of  consciousness  and  excludes  all  factors  in  conflict  with 
itself;  the  patient  beheves  in  his  royal  birth,  despite  the  com- 
mon place  facts  of  his  origin,  of  his  surroundings,  and  of  his 
actual  station  in  life. 

Dissociation  manifests  itself  in  many  other  ways.  Thus,  in 
hysteria,  as  already  pointed  out  (see  p.  263),  the  psychic 
representation  of  a  limb  or  of  one-half  of  the  body  may  be  cut 
out  of  the  field  of  consciousness,  or  the  dissociation  may  be  of 
such  a  character  as  to  result  in  a  cleavage  of  the  personality; 
as  in  hysteric  somnambulism  and  in  the  somnambulism  of 
hypnosis.  In  such  a  state,  the  patient  is  dominated  by  a  group 
of  ideas  which  are  entirely  dissociated  from  those  governing 
his  actions  in  his  normal  condition.  There  is  an  actual  separa- 
tion of  the  personality  into  two  parts.  Cases  of  more  or  less 
persistent  double  personality  (see  p.  264)  are  every  now  and 
then  observed  and  can  only  be  explained  by  dissociation.  At 
one  time  the  field  of  consciousness  is  occupied  by  one  system 
of  complexes  and  at  another  time  by  another  system,  there 
being  no  association  between  the  two. 

Again,  different  groups  of  ideas  may  occupy  the  field  of  con- 
sciousness during  successive  stages  of  a  given  disease.  Thus, 
in  the  paranoid  affections,  the  patient,  in  the  depressive  phase, 
presents  complexes  dealing  with  conspiracy  and  persecution, 
and,  in  the  expansive  phase,  complexes.dealing  with  importance. 


THE   PSYCHOLOGIC    INTERPRETATION   OF   THE   SYMPTOMS       385 

noble  birth,  exalted  station.  (See  Part  I,  Chapter  V.)  There 
is  here,  however,  no  sharp  separation,  no  sudden  transition 
from  one  group  of  ideas  to  the  other.  Indeed,  for  a  time 
they  may  co-exist;  the  expansive  ideas  crowd  the  depressive 
ideas  from  the  field  of  consciousness  gradually. 

Among  other  states  which  offer  interesting  examples  of  dis- 
sociation is  delirium.  Here  the  delusions  are  (see  p.  34  et  seq.) 
unsystematized,  unrelated,  fragmentary,  and,  it  may  be,  kalei- 
doscopic. Such  a  condition  can  only  be  explained  on  the  basis 
of  multiple,  constantly  changing,  and  transient  dissociations. 
There  seems  to  be  in  an  active  delirium  a  rapidly  and  constantly 
shifting  fragmentation  of  the  personality. 

The  presence  of  a  hallucination  implies  of  itself  a  dissociation. 
In  such  a  case,  a  separated  portion  of  the  personality  addresses 
itself  to  the  main  body  of  consciousness;  e.  g.,hy  words.  The 
impression  produced  is  that  of  a  sensation  of  extraneous  origin. 
Now  and  then  a  separated  portion  of  the  personality  expresses 
itself  in  writing;  that  is,  instead  of  the  patient  hearing  words 
and  sentences,  his  own  hand  may  automatically  write  them. 
The  general  consciousness  does  not  know  what  the  hand  is 
about  to  write  and  exercises  no  volition  or  direction  over  the 
hand;  the  effect  upon  the  main  personality  is  exactly  that  of 
a  hallucination;  i.  e.,  of  something  received  from  without. 
Such  instances  are  of  course  rare,  but  they  nevertheless  occur. 

In  the  case  of  an  illusion,  dissociation  is  incomplete,  or  rather 
association  is  imperfect  and  abnormal;  the  impression  is  not 
properly  correlated,  and,  therefore,  erroneously  apperceived. 
In  other  words,  it  is  misinterpreted.  (See  p.  22.) 

The  most  interesting  anomalies  of  association  are  presented 
by  the  neurasthenic-neuropathic  disorders,  the  psychasthenias. 
Here,  as  was  pointed  out,  the  one  distinguishing  feature  is  the 
formation  of  pathologic  associations.    (See  Part  I,  Chapter  VI.) 

25 


386  MENTAL    DISEASES 

In  part,  such  associations  may  be  referred  to  attacks  of  spon- 
taneous generalized  fear,  or  to  other  occurrences  giving  rise  to 
a  kindred  painful  emotional  state;  i.  e.,  dread,  dislike,  disgust, 
abhorrence.  Among  these  are  such  occurrences  as  a  reprimand 
at  school,  threatened  punishment  at  home,  an  unpleasant 
experience  in  business,  various  acts  of  the  patient,  breaches  of 
conduct,  of  the  proprieties,  peccadillos,  sexual  acts,  sexual  ex- 
periences and  transgressions,  in  short,  all  kinds  of  occurrences, 
the  recollection  of  which  is  unpleasant  or  painful  or  of  which 
the  patient  is  ashamed  and  which  he  tries  to  forget. 

The  mechanism  by  means  of  which  the  pathologic  association 
is  formed  is  probably  as  follows:  Under  normal  circumstances 
— that  is,  in  a  normal  individual — a  complex  may  enter  without 
let  or  hindrance  into  the  field  of  consciousness.  It  only  depends 
upon  the  trend  of  the  psychic  activity  of  the  individual  whether 
it  enters  or  not  at  a  given  time  into  consciousness.  If  so,  it 
is  grouped  with  other  complexes  already  there.  If  in  harmony 
with  the  latter,  it  joins  in  and  perhaps  in  some  degree  modifies 
the  current  of  thought.  If  it  be  in  disharmony,  it  may  greatly 
modify  the  current  of  thought,  or  there  may  be  for  a  time  an 
actual  conflict  between  divergent  groups  of  ideas.  The  indi- 
vidual may  under  such  circumstances  pass  through  a  period 
of  worry  and  stress,  but  finally  in  the  normal  individual  a  de- 
cision is  reached,  a  line  of  conduct  determined  upon,  and  the 
matter  settled.  For  instance,  a  business  man  has  the  oppor- 
tunity of  achieving  success  by  taking  an  unfair  advantage  of  a 
partner  who  has,  it  may  be,  been  his  life-long  friend.  The 
idea  occurs  to  his  mind,  but  meets  there  in  conflict  with  other 
ideas  based  upon  loyalty  and  affection.  The  conflict  may  be 
quite  severe;  the  opportunity  may  have  much  to  justify  it;  the 
partner  may  be  overconservative,  unprogressive,  and  a  hin- 
drance; on  the  other  hand,  the  course  suggested  by  the  idea 


THE  PSYCHOLOGIC  INTERPRETATION  OF  THE  SYMPTOMS   387 

might  bring  the  friend  and  his  family  to  want;  cause  pain  and 
suffering  to  innocent  persons.  In  a  normal  individual  the  prob- 
lem is  thought  out  and  definitely  settled.  In  a  weak  or  neuro- 
pathic man  the  idea  may  be  put  aside,  repressed,  never  wholly 
disposed  of,  only  to  recur  later  in  some  new  and  unrecognized 
form;  it  may  be  as  a  sense  of  pity  for  himself,  of  antipathy  for 
his  partner,  or  of  some  trick  of  habit  or  conduct  about  his  office 
subconsciously  based  upon  this  antipathy. 

If  the  complex  concerns  some  action  of  the  individual,  the 
memory  of  which  is  unpleasant  or  painful,  and  which  he  is 
anxious  to  forget,  the  troublesome  complex  may  be  suppressed 
altogether,  may  not  be  permitted  to  enter  the  field  of  conscious- 
ness at  all.  Usually,  however,  the  attempt  at  repression  is  only 
partially  successful.  The  buried  complex  is  still  potential; 
it  links  itself  to  other  perhaps  subconscious  complexes,  and, 
finally,  by  an  indirect  pathway,  reaches  the  field  of  conscious- 
ness, though  it  does  so  in  a  converted  or  distorted  form.  Per- 
haps it  makes  its  appearance  in  a  feeUng  of  uneasiness,  of  anxiety, 
of  an  apparently  unexplained  fear  or  obsession,  or,  it  may  be, 
in  some  strange  movement,  a  tic,  defensive,  protective,  or 
apparently  senseless.  (See  p.  190.)  Such  reactions,  it  must 
be  clearly  borne  in  mind,  can  only  take  place  in  individuals 
already  the  victims  of  a  pre-existing  neuropathy.  Such  phenom- 
ena are  not  observed  in  persons  of  a  normal  nervous  make-up. 

The  repression  of  complexes  leads  to  interesting  phenomena 
other  than  those  revealed  in  neurasthenic-neuropathic  and  hys- 
teric states;  indeed,  many  of  them  are  observed  in  normal  in- 
dividuals. Thus  the  constant  repression  of  the  sexual  impulse 
may  lead  to  an  exaggeration  of  modesty — i.  e.,  to  prudery;  the 
repression  of  the  maternal  instinct  may  lead  to  the  lavish  ex- 
penditure of  the  affections  on  cats,  dogs,  and  other  pets.  In 
pathologic  states  the  reactions  may  be  more  complex.     Thus,  the 


388  MENTAL    DISEASES 

repression  of  the  sexual  instinct  may  lead  a  woman  to  attribute 
her  repressed  feelings  to  others;  may  make  her  feel  that  she  is 
being  desired  and  sought  after.  She  may  imagine  that  every  man 
is  in  love  with  her,  or  she  may  center  upon  some  one  man  who, 
she  believes,  is  paying  her  attention.  She  may  not  have  more 
than  a  passing  acquaintance  with  the  object  of  her  thoughts; 
indeed,  the  latter  is  usually  quite  unmindful  of  her  existence. 
She  is  herself  sexually  attracted  to  the  man  and  represses  or 
does  not  consciously  admit  this  fact.  On  the  contrary,  she 
ascribes  the  feeling  to  the  man,  and  interprets  an  every-day 
greeting,  a  passing  remark,  or  other  commonplace  incident  as 
proof  that  the  man  is  pursuing  her  with  his  attentions.  Grad- 
ually she  evolves  a  series  of  systematized  delusions,  which 
sooner  or  later  assume  the  character  of  annoyance  and  perse- 
cution. It  is  this  condition  which  Clouston  termed  "old  maids' 
insanity."  Quite  frequently  the  patient  is  in  the  early  forties, 
or  near  or  at  the  menopause.  The  explanation  of  such  a  "pro- 
jection" of  the  sexual  feeUngs  is  probably  to  be  explained  as 
follows:  Long  repressed,  the  sexual  complex  becomes  so  far 
separated  from  the  general  personality,  that,  as  in  the  instance 
of  a  hallucination,  it  finally  reacts  upon  the  main  body  of  con- 
sciousness like  a  separated  portion  of  the  personality,  and  is 
therefore  attributed  by  the  patient  to  some  one  person  or  per- 
sons without.  The  delusive  ideas  may  not  limit  themselves 
merely  to  those  of  annoyance  and  persecution  by  the  attentions 
of  the  supposed  lover,  but  may  become  much  farther  developed. 
Thus  the  patient  may  believe  that  her  minister  or,  it  may  be, 
her  physician  has  assaulted  or  seduced  her  or  been  guilty  of  other 
misconduct,  and  she  may  cite  the  most  trifling  incidents  in  proof 
of  her  assertions.  At  times  the  repression  of  the  sexual  complex 
presents  another  picture.  The  patient  begins  to  take  an  undue 
interest  in  rumors,  gossip,  stories  of  a  sexual  nature.    Soon  these 


THE    PSYCHOLOGIC    INTERPRETATION    OF    THE    SYMPTOMS     389 

concern  her  neighbors,  intimates,  friends,  various  members  of 
her  social  circle.  Little  by  little  she  becomes  the  vehicle  and 
disseminator  of  these  tales,  usually  woven  out  of  the  whole 
cloth,  and  she  may  finally  end  by  becoming  a  virulent  scandal- 
monger. At  other  times,  instead  of  evidencing  her  mental 
attitude  by  word  of  mouth,  she  may  secretly  attack  the  reputa- 
tion of  various  persons  by  letters.  The  latter,  which  are  almost 
always  anonymous  and  usually  grossly  indecent  and  obscene, 
may  be  addressed  to  the  victims  themselves,  or  to  numerous 
other  persons.  These  cases  constitute  the  so-called  "poisoned 
pen"  cases  of  the  pubUc  press  and  of  the  courts.   (See  also  p.  167.) 

The  tendency  to  project  our  own  buried  impulses  and  desires 
is  seen  quite  frequently  in  normal  life,  as  when  a  man  criticizes 
in  others  the  faults  he  himself  possesses ;  when  the  fault  happens 
to  be  associated  with  some  unpleasant  fact  or  memory  of  miscon- 
duct of  his  own,  his  condemnation  becomes  the  more  emphatic. 
It  is  not  an  accident  that  the  man  who  betrays  a  financial 
trust  is  sometimes  unusually  prominent  in  religious  affairs,  an 
ardent  Sunday-school  teacher,  or  an  austere  pillar  of  the  church. 
It  is  but  a  short  step  to  ascribe  insincerity,  dishonesty,  and  wick- 
edness to  the  rest  of  the  world,  or,  it  may  be,  to  a  certain  group 
of  men  or  to  a  particular  individual.  In  neuropathic  persons 
the  transition  to  delusions  of  conspiracy  and  persecution  readily 
follows. 

Of  late  years,  a  new  school  has  arisen  in  Vienna  which,  under 
the  leadership  of  Freud,  has  devoted  itself  to  the  interpretation 
of  the  neuroses  and  allied  states,  and  has  been  extended  by 
Bleuler  and  Jung  to  the  interpretation  of  the  phenomena  of 
dementia  prsecox.  A  procedure  was  evolved  which  has  received 
the  rather  imposing  and  suggestive  name  of  psychanalysis,  and  by 
its  means  the  hidden  origin  of  various  phobias,  delusions,  and 
other  symptoms  are  supposed  to  be  unraveled.    Painful  and  re- 


390  MENTAL    DISEASES 

pressed  memories  are  given  free  vent,  and  the  patient — so  it  is 
claimed — cured.  At  the  very  outset  of  our  inquiry' into  the  method 
it  becomes  apparent  that  Freud  and  his  disciples  are  obsessed  by 
the  single  factor  of  sex.  In  their  eyes  every  sjTuptom,  every 
phobia,  delusion,  impulse  or  obsession  has  its  origin  in  the 
repressed  memory  of  some  sexual  experience,  some  sexual  trauma 
received  in  childhood;  further,  every  dream  has  a  sexual  origin, 
has  a  sexual  content  and  a  sexual  significance,  and,  according 
to  Freud,  dreams  thus  constitute  a  powerful  factor  in  the  pro- 
duction of  mental  sjinptoms.  In  order  that  we  should  be  able 
to  form  a  proper  judgment  of  both  of  the  method  and  of  the 
claims  of  its  votaries,  it  will  be  necessary  to  accord  it  a  brief 
consideration. 

To  begin,  psychanalj''sis  is  an  evolution  from  other  and  rel- 
atively simpler  procedures,  and  the  latter,  in  turn,  had  their 
origin  in  practices  in  which  superstition  and  magic  played 
the  essential  roles.  Space  will  not  permit  of  even  the  enumera- 
tion of  the  manj^  mystic  and  religious  practices  of  ancient  times, 
nor  of  the  survivals  of  these  in  later  days.  Suffice  it  to  say 
that  among  them  were  various  theories  of  animal  magnetism,  ad- 
vocated by  Pompinatius,  Agrippa,  Paracelsus,  Bacon,  Van  Hel- 
mont,  and  others.  These  theories  in  due  course  found  their 
maximum  exponent  in  Mesmer,  who  in  1774  emploj^ed  magnets 
in  the  treatment  of  every  possible  affection.  His  results  were 
little  short  of  the  marvelous,  and  his  supply  of  magnets  becoming 
exhausted,  he  discovered  that  he  could  produce  the  same  effects 
by  passes  and  gestures.  He  believed  that  animal  magnetism 
was  derived  from  the  heavenly  bodies.  His  theories  and  prac- 
tises, as  is  well  known,  survived,  with  varying  fortunes,  until 
Braid,  in  England,  introduced  a  formal  method  in  which,  though 
the  theorj'-  of  animal  magnetism  was  denied,  similar  results 
were  produced.    This  method,  which  was  characterized  mainly 


THE    PSYCHOLOGIC    INTERPRETATION    OF    THE    SYMPTOMS     391 

by  fixation  of  the  eyes  upon  a  bright  object,  was  originally 
known  as  braidism.  This,  in  turn,  gave  way  to  hypnotism,  in 
which,  during  the  artificial  sleep  produced,  suggestions  of  various 
kinds  were  made  to  the  subject.  In  due  course,  it  was  discovered 
that  the  phenomena  observed  in  hypnosis  were  identical  with 
those  of  hj^steria;  in  other  words,  hj'pnosis  was  found  to  be 
merely  a  state  of  hj^steria  artificially  evoked.  How  extensively 
hypnotism  was  employed  in  the  treatment  of  nervous  affections 
is  a  matter  of  history;  so  much  so,  indeed,  as  to  make  a  special 
account  unnecessary.  Suffice  it  to  say,  that  in  the  early  80's 
Breuer,  of  Vienna,  in  common  with  many  other  physicians  the 
world  over,  was  practising  hj^notism.  He  observed  among 
other  things  that  whenever  he  was  successful  in  arousing  in  the 
patient  the  memor}-  of  the  occurrence  which  had  given  rise  to  his 
(the  patient's)  special  sATnptom,  and  if,  at  the  same  time,  the 
patient  could  be  induced  to  give  a  full  account  of  the  occurrence 
and  also  to  give  vent  verbally  to  the  associated  emotion,  the 
sjTQptom  disappeared.  That  is,  the  mind  was  purged  of  its 
repressed,  painful  memory,  and  Breuer  termed  this  proceeding 
catharsis.  Later  he  was  joined  by  Sigmund  Freud.  Breuer, 
let  it  be  emphasized,  hypnotized  his  patients  and  then  tried  to 
ehcit  from  them  memories  of  past  occurrences.  It  is  significant 
further  to  add  that  in  this  procedure  he  did  not  rely  solely 
upon  the  spontaneity  of  the  patient,  but,  to  use  his  own  words, 
made  use  of  "medical  suggestion"  as  is  done  "in  somnambuhsm 
with  amnesia."  That  memories  eA'oked  under  hj-pnosis — i.  e'., 
under  artifically  induced  hysteria — are  worthless  and  fictitious 
is  a  matter  of  common  knowledge.  Indeed,  that  patients 
suffering  from  hysteria  react  in  the  same  way  T\dthout  the  pre- 
vious induction  of  hypnotism  is  like\^dse  well  known.  That 
this  was  iuRy  recognized  by  Breuer  and  Freud  is  proved  by  the 


392  MENTAL    DISEASES 

fact  that  in  their  book  "Studicn  ueber  Hysteric"  they  speak  of 
the  "hypnoid  states"  of  their  patients. 

Subsequently  Freud  made,  as  he  believed,  an  important  modi- 
fication: he  dispensed  with  hypnotism  and  then  renamed  the 
procedure  psychanalysis.  A  moment's  reflection  will  convince 
the  reader  that  while  Freud  dispensed  with  formal  hypnotism — 
i.  e.,  while  he  no  longer  made  use  of  braidism,  passes,  sleep  sug- 
gestions and  the  like — it  was  impossible  for  him  to  dispose  of  the 
hypnoid  state;  for  we  have  learned  that  hysteria  and  hypnosis 
are  identical  conditions.  Finally,  the  technic  instituted  by 
Freud  was  such  as  to  lead  inevitably  to  a  greater  or  lesser 
induction  of  autohypnosis.  The  patient  was  placed  upon  her 
back  upon  a  couch  and  was  spared  every  possible  muscular 
effort  and  every  diverting  sensory  impression,  such  as  might 
disturb  her  in  her  concentration  on  her  "internal  psychic  proc- 
esses." In  other  words,  psychanalysis  is  but  the  final  stage  of  a 
series  of  procedures  of  which  animal  magnetism  was  the 
beginning,  and  mesmerism,  braidism,  hypnotism,  and  catharsis 
the  successive  and  intermediate  phases. 

Let  us  pursue  Freud's  method  a  little  farther.  Freud  en- 
deavors to  obtain  access  to  the  memories  of  the  patient  from 
the  very  earliest  experiences  of  the  latter  onward.  She  is  re- 
quested to  tell  everything  that  comes  into  her  mind,  whether 
she  thinks  it  important  or  unimportant,  whether  it  seems  rele- 
vant or  senseless.  She  is  especially  requested  not  to  suppress 
any  thought  or  idea  because  this  idea  happens  to  be  shameful 
or  painful.  In  the  very  beginning  of  the  account  given  by  the 
patient,  lapses  of  memory  become  apparent.  These  may  have 
to  do  with  every-day  occurrences  which  have  been  forgotten, 
or  to  relations  of  time  or  of  cause  which  have  become  disturbed, 
so  that  results  are  obtained  which  cannot  be  understood.  Freud 
claims  that  no  neurotic  history  can  be  elicited  which  does  not 


THE    PSYCHOLOGIC    INTERPRETATION    OF    THE    SYMPTOMS     393 

reveal  amnesias  of  some  form  or  other.  If  the  patient  be  urged 
to  fill  up  these  lapses  of  memory  by  an  increased  effort  of  at- 
tention, it  is  noted,  says  Freud,  that  the  ideas  which  now  occur 
are  repressed  with  every  effort,  until  finally,  if  the  memory  really 
appears,  the  patient  experiences  a  marked  sense  of  discomfort. 
From  this  observation  Freud  concludes  that  the  lapses  or  lacunae 
of  memory  are  the  result  of  a  mental  action  which  he  terms  re- 
pression (Verdrangung),  and  as  the  motive  of  this  repression  he 
recognizes  feelings  of  aversion  or  dislike.  The  agents  which  have 
brought  about  this  repression  he  believes  he  recognizes  in  the 
resistance  which  is  offered  to  the  memory  reproduction.  He 
regards  the  ideas  which  appear  under  these  circumstances 
as  derivatives  of  the  suppressed  psychic  pictures;  as  trans- 
formations of  the  same,  the  direct  result  of  the  resistance 
offered  to  their  reproduction.  The  greater  the  resistance,  the 
more   pronounced  is  this  transformation. 

The  truth  of  the  memories  elicited  from  a  patient  under  the 
above  conditions  may  very  justly  be  questioned.  How  little  re- 
hance  can  be  placed  upon  the  sayings  of  patients  in  hypnosis  and 
the  hypnoid  state  of  hysteria  has  already  been  pointed  out. 
Further,  that  the  patient  responds  readily  to  the  slightest  sug- 
gestion received  from  without  goes  without  saying,  and  that 
the  physician  makes  such  suggestions  unintentionally  and  invol- 
untarily there  can  be  no  doubt.  The  seance,  says  Freud,  has 
the  character  of  "a  conversation  between  two  persons";  and  the 
fact  that  the  psychanalyst  always  finds  that  which  he  is  seeking 
to  find  leaves  no  room  for  doubt.  He  invariably  finds  the  re- 
pressed memory  of  some  sexual  misconduct,  some  sexual  trans- 
gression, some  sexual  trauma  experienced  in  childhood. 

It  may  be  safely  said  that  whatever  of  truth  there  is  in  the 
relation  of  repressed  complexes  to  the  production  of  various 
mental  symptoms,  had  already  been  pointed  out  by  Janet  in  his 


394  MENTAL    DISEASES 

discussion  of  psychasthenia.  (See  p.  187.)  Janet  clearly  indi- 
cated the  role  in  the  evolution  of  the  phobias,  obsessions,  states 
of  indecision  and  the  like,  of  occurrences  in  the  patient's  past 
of  which  the  latter  is  ashamed,  the  recollection  of  which  is 
painful  and  which  he  tries  to  forget.  The  psychanalysts  have 
uniformly  failed  to  give  to  Janet's  discovery  recognition  and 
have  restricted  all  causes  to  the  sexual  factor.  To  this  sexual 
factor  which  at  times  is  represented  by  the  memory  of  a  sexual 
trauma,  at  others  bj'  a  repressed  sexual  desire,  they  have  given 
the  name  "the  libido."  Freud  believes  that  the  sjonptoms 
always  have  their  origin  in  some  passionate  sexual  aggression 
of  childhood.  Others  than  myself  have  dwelt  on  the  glaring 
inconsistency  implied  by  the  sexual  immaturity  of  children  and 
the  intrinsic  biologic  improbability  of  this  view. 

Freud,  as  alread}^  stated,  further  believes  that  in  the  study  of 
dreams  we  have  a  method  of  access  to  repressed  memories. 
These  memories  are  always  of  sexual  occurrences,  often  of  sup- 
pressed sexual  desires,  which  in  the  dream  are  represented  as 
fulfilled.  The  patient,  in  a  dream  analysis,  is  requested  to  make 
an  oral  statement  of  the  dream  or  to  give  an  account  in  writing, 
and  in  so  doing  he  is  to  communicate  every  idea  without  exception 
that  occurs  to  him  in  connection  with  the  dream.  Ordinarily,  ac- 
cording to  Freud,  a  person  thinking  about  a  dream  will  reject 
this  or  that  idea  suggested  by  the  dream  as  unimportant  and  as 
having  no  connection  with  the  dream.  It  is  this  censor  or  critic, 
as  Freud  calls  it,  which  under  ordinarj''  circumstances  causes  the 
patient  to  reject  certain  ideas  from  the  communication;  but 
if  the  patient  can  withhold  the  critic,  in  thinking  over  the 
substance  of  a  dream,  a  psychic  material  is  furnished  which 
leads  to  the  solution  or  unraveling  of  the  dream. 

Every  dream,  according  to  Freud,  has  a  manifest  or  apparent 
content,  that  which  appears  on  the  surface  of  the  recital,  and 


THE    PSYCHOLOGIC    INTERPRETATION    OF    THE    SYMPTOMS     395 

a  latent  content;  i.  e.,  the  material  derived  from  the  dream 
when  the  patient  gives  himself  up  to  the  unrestrained  associa- 
tion of  ideas  which  ensues  when  he  dwells  upon  the  dream. 
Further  dreams  reveal,  in  addition,  a  process  of  condensation. 
Thus,  when  we  compare  the  number  of  ideas  contained  in  a 
dream,  as  written  down  from  memory,  with  the  number  of 
ideas  revealed  in  the  latent  dream  content,  it  becomes  apparent 
that  a  very  great  condensation  has  taken  place.  We  do  not 
find  a  single  factor  of  the  dream  content  from  which  threads  of 
association  do  not  lead  into  three  or  more  different  channels; 
there  is  no  situation  which  is  not  pieced  together  out  of  three 
or  four  impressions  and  experiences. 

During  the  process  of  ehciting  the  latent  dream  content, 
the  mind  passes  from  the  thoughts  and  conceptions  to  which  it 
by  right  belongs  to  others  which  have  no  claim  to  such  an  em- 
phasis or  importance,  and  it  is  this  process  which  has  to  do 
with  the  concealment  of  the  meaning  of  the  dream  and  with 
making  it  unintelligible.  This  process,  to  which  Freud  ascribes 
great  importance,  he  terms  "dream-displacement"  or  Traum- 
verschiebung.  It  would  seem  that  that  which  is  most  vivid 
in  the  dream  content  would  be  the  most  important,  but,  ac- 
cording to  Freud's  theory,  it  is  precisely  in  an  obscure  dream 
element  that  he  finds  the  direct  evidence  of  the  most  important 
.  dream  thoughts. 

The  kernel  of  the  problem,  says  Freud,  lies  in  the  displace- 
ment. The  essential  condition  of  the  displacement  is  a  purely 
psychologic  one.  It  is  of  the  nature  of  a  play  of  motives  or 
activation  of  motives.  We  ascertain  the  cause  of  this  activa- 
tion of  motives  when  we  realize  that  we  are  compelled  to  break 
off  in  communicating  the  contents  of  a  dream,  because  thoughts 
present  themselves  which  cannot  be  revealed — cannot  be 
spoken  of  to  others— without  the  injury  of  most  important  con- 


396  MENTAL    DISEASES 

siderations,  personal  and  private.  Freud  asserts  that  this  is 
true  of  the  content  of  every  dream ;  that  every  dream  contains 
thoughts  which  necessitate  privacy.  If,  Freud  says,  he 
pursues  the  dream-thought  for  himself,  he  arrives  finally  at 
thoughts  which  surprise  him,  which  he  did  not  know  existed  in 
him,  and  which  not  only  appear  strange  to  him,  but  are  also 
unpleasant,  and  which  he,  for  this  reason,  would  energetically 
resist.  Freud  says  that  he  cannot  do  otherwise  than  to  suppose 
that  these  thoughts  are  really  present  in  his  soul-life  (his  sub- 
consciousness?), and  possess  a  certain  psychic  intensity  or 
energy,  but,  because  they  had  been  in  a  pecuUar  psychologic 
situation,  they  could  not  become  kno^\^l  to  him;  i.  e.,  could  not 
reach  his  consciousness.  He  terms  this  condition  Verdrangung, 
repression.  He  says  he  cannot  refrain  from  concluding  that 
between  the  obscurity  of  the  dream  content  and  the  condition 
of  repression  there  is  a  causal  relationship,  and  he  concludes 
that  the  dreams  had  to  be  obscure  in  order  that  the  tabooed 
dream-thoughts  should  not  reveal  themselves.  The  misrepre- 
sentation of  the  dream  serves  to  conceal  the  latter. 

Freud  believes  that  the  dream-work,  "Traumarbeit,"  is  one 
of  a  series  of  psychic  processes  to  which  the  origin  of  hysteric 
symptoms,  phobias,  obsessions,  and  delusions  are  to  be  ascribed. 
Condensation  and  especially  displacement  are  characters  never 
wanting  in  the  other  processes  as  well.  Freud  believes  that  a 
whole  train  of  phenomena  of  the  every-day  life  of  normal  in- 
dividuals— forgetfulness,  unconscious  mistakes  in  speech,  in 
simple  acts  and  other  errors — are  due  to  analogous  psychic 
mechanisms. 

Freud's  therapeutic  application  of  the  dream  consists  in 
having  the  patient  submit  himself  to  the  procedure  already 
outlined,  i.  e.,  of  allowing  all  of  the  thoughts  suggested  by  the 
dream,  no  matter  what  their  character,  to  find  verbal  expression^ 


THE    PSYCHOLOGIC    INTERPRETATION    OF    THE    SYMPTOMS     397 

and,  just  as  in  his  method  of  free  association,  the  suppressed, 
painful,  or  shameful  thought  thus  finds  a  vent.  Freud  assumes 
that  even  in  the  deepest  sleep  a  certain  degree  of  psychic 
activity  is  present  which  manifests  itself  as  a  watchfulness  or 
guardianship  over  the  sleeper.  This  guardian-like  attention 
or  watchfulness  concerns  itself,  among  other  things,  with  a 
suppressed  sexual  desire,  and  forms  with  the  latter  the  dream, 
the  dream  being  a  compromise  of  this  guardian-like  attention 
and  suppressed  desire.  Thus  is  produced  a  kind  of  psychic 
relief  for  the  suppressed  desire,  for  the  dream  represents  the 
desire  as  fulfilled. 

Whether  it  is  true  that  every  dream  has  a  sexual  content 
may  be  safely  left  to  the  sober  testimony  of  human  experience. 
It  is  extremely  probable  that  the  method  employed  by  Freud 
of  itself  suggests  the  memories  of  sexual  occurrences;  sometimes, 
too,  there  is  reason  to  believe  that  the  memory  eficited  is  ficti- 
tious. The  dream  is  so  often  retold  and  rewritten — usually  after 
visits  to  the  psychanalyst — that  the  material  finally  obtained 
has  about  as  much  value  as  that  obtained  by  the  other  method; 
and  into  this  material  the  psychanalyst,  as  before,  reads  the 
phantasies  of  his  own  autosuggestions. 

It  is  extremely  probable,  further,  that  the  psychology  of 
dreams  is  not  nearly  as  complex  as  the  psychanalysts  would  have 
•  us  believe.  In  all  probability,  dream  conceptions  arise  j ust  as  the 
sleeper  is  in  the  act  of  awakening,  i.  e.,  of  entering  into  conscious- 
ness, or  during  such  intervals  or  periods  of  sleep  in  which  the 
sleep  becomes  relatively  light,  so  that  the  level  of  consciousness 
is  approached  or  perhaps  nearly  reached.  There  is  in  every  act  of 
awakening  an  intermediate  twilight  state  of  mind,  usually  very 
brief,  but  sometimes  prolonged.  Dream  conceptions  have  their 
origin  apparently  in  vague  sensory  impressions  reaching  the 
imperfectly  submerged  consciousness  from  without;  or,  perhaps, 


398  MENTAL    DISEASES 

at  times  they  are  somatic  in  origin.  At  any  rate,  their  arrange- 
ment into  some  semblance  of  order  and  sequence  occurs  subse- 
quently to  the  act  of  awakening.  Usually,  too,  this  arrange- 
ment is  automatic,  but  such  material  is  capable  of  endless 
manipulation  in  the  way  of  interpretation,  and  when  submitted 
to  the  vagaries  of  a  procedure  indistinguishable  in  its  character 
from  a  hypnosis  may  yield  anything  that  the  psychanalyst 
is  looking  for. 

Another  method  of  bringing  to  light  repressed  or  submerged 
complexes  is  that  of  the  association  test,  applied  by  Jung  and 
others.  The  patient  is  told  that  as  soon  as  he  hears  a  given 
word,  he  is  to  utter  at  once  the  first  word  or  thought  that 
comes  into  his  mind.  A  series  of  words  is  then  read  to  him,  and 
the  time  elapsing  between  the  reading  of  the  word  and  the  reply 
is  recorded  by  a  stop-watch.  If  now  it  be  found  that  the  time 
elapsing — the  reaction  time — is  suddenly  increased,  as  though 
there  were  a  brief  period  of  hesitation,  it  is  probable  that  a  com- 
plex has  been  aroused.  The  word  read  by  the  investigator  is 
the  stimulus  word;  the  word  uttered  in  reply,  the  reaction  word; 
and  a  word  which  betrays  an  increase  in  time  reaction  may  prove 
to  be  a  complex  indicator.  An  ordinary  reaction  may  require 
between  one  and  two  seconds ;  say,  from  one  and  two-tenths  to  one 
and  eight-tenths  seconds ;  if  the  reaction  time  is  suddenly  length- 
ened to  three,  four,  or  five  seconds,  there  is  reason  to  suspect 
the  existence  of  a  repressed  complex.  The  list  of  words  should 
be  reasonably  long,  and  should  contain,  in  addition  to  miscel- 
laneous words  expressive  of  various  objects  and  actions,  also  a 
carefully  selected  number,  based  upon  the  possibihties  which  a 
previous  general  study  of  the  case  has  suggested  to  the  examiner; 
these  words  should  be  interspersed  at  irregular  intervals.  In 
addition  to  the  increased  time  required,  the  reaction  word 
may  also  be  significant  if  the  association  be  unusually  obscure 


THE    PSYCHOLOGIC    INTERPRETATION    OF    THE    SYMPTOMS     399 

or  apparently  non-existent.  Again,  it  is  also  significant  if, 
after  a  reaction  word  with  increased  time  has  been  noted,  delay, 
though  less  in  degree,  is  observed  in  the  next  word  or  two  fol- 
lowing. It  would  seem  as  though  the  patient  had  been  shghtly 
disturbed  and  the  disturbance  transmitted  to  the  immediately 
succeeding  tests.  It  seems  almost  unnecessary  to  add  that  the 
results  attained  by  this  method  are  commonly  quite  trivial  and, 
further  and  above  aU,  are  again  subject  to  the  personal  vagaries 
of  interpretation  of  the  psychanalyst. 

It  remains  to  summarize  briefly  some  of  the  essential  features 
of  the  psychology  advocated  by  the  freudian  sect.  In  the  first 
place  they  create  out  of  nothing  a  censor,  a  wide  awake  critic, 
guarding  the  dream  of  the  sleeper;  secondly,  they  create  an  un- 
conscious something  which  in  like  manner  guards  us  during  the 
waking  period  and  shoves  unpleasant  and  painful  memories  into 
the  subconscious.  How  completely  the  latter  fails  when  the  in- 
dividual has  a  real  worrj^,  such  as  a  business  reverse,  a  finan- 
cial disaster,  the  death  of  a  beloved  child,  or,  it  may  be,  the 
recollection  of  a  crime,  is  a  matter  of  human  experience.  Third- 
ly, all  of  the  phenomena  observed  in  both  dreams  and  waking 
periods  are  interpreted  in  terms  of  the  sexual  desire,  the  libido. 
Fourthly,  the  ideas  presented  by  the  dream  or  which  are  revealed 
in  the  waking  period  do  not  signify  what  they  appear  to  signify, 
but  are  masked  and  disguised.  In  other  words,  they  are  merely 
sexual  symbols.  As  there  is  not  a  single  object  in  the  range  of 
human  ken  to  which  a  sexual  significance  cannot  be  ascribed, 
the  task  of  the  psychanalyst  is  easy.  If  the  object  be  elongated 
or  if  it,  perchance,  have  a  cavity  the  question  is  already  answered; 
it  may  be  a  key,  a  lock,  a  snake,  an  open  fire-place,  a  lead  pencil, 
a  cup,  or  anything  else  imaginable.  The  horse,  too,  and  other  ani- 
mals are  favorite  symbols.  Further,  at  times  the  sjonbols  sug- 
gest one  thing  and  at  other  times  the  exact  opposite.    One  thing 


400  MENTAL    DISEASES 

is  clear,  however;  the  interpretation  always  depends  upon  the 
psychanalyst,  upon  his  resourcefulness,  the  fertility  of  his  imag- 
ination; in  other  words,  upon  his  own,  his  autosuggestion.  The 
conclusion  already  exists  preformed  in  his  mind  that  the  patient 
is  suffering  from  repressed  sexual  memories;  and  that  he  finds 
them  goes  without  saying.  Indeed,  that  he  finds  everything  he 
is  looking  for  we  have  already  seen. 

Frequently,  the  libido  is  expressed  in  terms  gross  and  ob- 
scene; at  other  times  it  is,  as  the  psychanalysts  explain,  subli- 
mated; that  is,  it  becomes  refined,  allusive,  transformed. 
However,  the  objection  to  psychanalysis  lies  not  so  much  in  its 
details,  as  in  the  hopelessly  illogical  position  of  its  votaries. 
Thus,  it  began  with  the  theory  of  sexual  traumas  in  childhood; 
these  have  now  been  carried  back  by  Ferenczi  into  the  period  of 
intra-uterine  life.  Further,  in  the  act  of  passing  through  the 
pelvis  of  its  mother,  the  child  is  badly  frightened,  and  the  fear 
which  it  experiences  is  the  prototype  of  the  attacks  of  fear  from 
which  it  suffers  at  later  periods  in  its  life.  Such  attacks  awake 
the  memory  of  this  birth  fear.  Further  still,  the  child  finds  itself 
in  a  state  of  auto-eroticism.  At  three  or  four  years  of  age,  it  is 
already  sexually  aggressive,  and  the  dominating  factor  is  now  in- 
cestuous love.  Indeed,  from  now  on  the  "(Edipus  complex" 
plays  a  large  role  in  its  life.  Henceforth  the  future  of  the  indi- 
vidual is  dominated  by  his  eroticism.  All  of  his  tendencies,  all 
of  his  peculiarities — good,  bad,  criminal — are  the  result  of  the 
libido.  In  his  dreams  and  in  his  neuroses,  he  rehearses  not  only 
the  life  of  the  child,  but  that  of  primitive  man.  If  he  have  the 
misfortune  to  suffer  from  an  epileptic  attack,  the  latter  is  ex- 
plained as  an  overpowering  of  the  moral  consciousness  by  the 
criminal  unconsciousness;  the  attack  replaces  the  sinful  sexual 
act.  Melancholia  and  mania,  too,  are  explained  as  repressions 
and  displacement  of  sexual  desire;  i.  e.,  of  the  transformed  libido. 


THE    PSYCHOLOGIC    INTERPRETATION    OF    THE    SYMPTOMS     401 

Paranoia  is  explained,  on  the  other  hand,  as  an  irritation  of  the 
anal  erogenous  zone,  and,  on  the  other,  as  an  expression  of 
homosexual  love.  Every  possible  affection  is  explained  by  the 
libido.  The  list  recently  furnished  by  an  American  writer  in- 
cludes practically  all  diseases  except  the  exanthemata. 

One  word  more  and  our  consideration  of  psychanalysis  will 
have  been  completed.  It  is  a  favorite  theme  with  psychanalysts 
to  draw  an  analogy  between  the  evolution  of  the  body  and  the 
evolution  of  the  mind.  That  the  body  has,  in  the  course  of  the 
countless  ages  required  for  its  development,  passed  through  many 
successive  stages  and  transformations  is  a  deduction  which  rests 
upon  familiar  facts  furnished  by  both  phylogeny  and  ontogeny — 
by  both  biological  history  as  revealed  by  comparative  anatomy 
and  paleontology,  on  the  one  hand,  and  by  embryology,  on  the 
other.  That  the  brain,  the  organ  of  mind,  has  taken  part  in 
this  evolution  goes,  of  course,  without  saying;  and  that  like  all 
parts  of  the  organism  it  bears  in  its  structure  the  record  of  this 
evolution  is  doubtless  equally  true.  It  must  be  freely  admitted, 
also,  that  this  must  necessarily  be  true  of  the  mind  as  well.  This 
is  perhaps  what  the  psychanalyst  tries  to  convey  when  he  says 
that  the  dream  and  the  neuroses  embrace  not  only  the  life  of  the 
child,  but  also  that  of  the  savage  and  primitive  man;  or  when 
he  states  that  the  patient  suffers  from  reminiscences  of  humanity 
and  that  his  history  embraces  all  mythology.  Stated  in  less 
fanciful  phrases  it  means  that  our  mental  embryology  like  that 
of  the  body  rehearses  in  a  measure  the  various  steps  of  the  mental 
evolution  of  the  race.  While  the  probable  and  general  truth  of 
this  inference  may  be  admitted,  the  psychanalyst  now  falls 
short  of  the  final  conclusion,  which  is  this:  Just  as  the  body 
may  reveal  the  evidences  of  arrest  and  deviation  of  development, 
so  may  the  mind.  That  such  arrests  run  parallel  with  arrests  of 
the  brain  is  shown  by  our  studies  of  the  brains  of  idiots  and 

26 


402  MENTAL    DISEASES 

feeble-minded  children;  and  when  we  deal  with  patients  suffer- 
ing from  the  neuroses  and  mental  affections  generally,  we  are 
dealing  with  individuals  of  whom  it  is  equally  true  that  they 
are  organically  defective.  This  in  its  essence  is  what  is  meant 
by  neuropathic  and  neurotic.  The  neuroses,  psychasthenia, 
hysteria,  and  hypochondria  present  not  only  in  the  history  of 
heredity  but  also  frequently  upon  the  verj-  person  of  the  patient, 
the  evidences  of  an  imperfect  or  a  deviate  development.  Men- 
tally, likewise,  the  neuroses  in  turn  present  deficiencies  and 
deviations  which  give  to  each  its  basic  sjnuptomatology  and 
which  in  each  are  innate  and  developmental.  Claims'of  cure  by 
psychanalysis,  are  therefore,  in  these  affections,  as  fallacious  as 
in  the  case  of  hypnosis.  One  could  with  equal  reason  expect  to 
cause  a  hareHp  or  a  cleft  palate  to  grow  and  become  normal  by 
talking  at  it,  or  to  cause  a  supernumerary  digit  or  a  cervical  rib 
to  disappear  by  hypnotizing  or  psychanalyzing  the  patient.  At 
most,  surface  symptoms  alone  can  be  played  upon;  the  under- 
lying basic  condition  can  never  be  in  the  slightest  degeee  in- 
fluenced.   (See  also  chapter  on  Treatment.) 

Let  us  now  turn  our  attention  to  the  psychology  of  dementia 
praecox.  We  are  at  once  impressed  by  the  fact  that  in  the  be- 
ginning the  symptoms  are  not  those  of  dementia,  but  those  of 
confusion,  just  such  symptoms  as  we  should  expect  in  a  toxic 
state.  The  onset  of  sjrmptoms  is  gradual,  usually  bearing  the 
character  of  a  confusion,  sometimes  with  elements  of  systematiza- 
tion  and  accompanied  by  exhaustion.  The  elements  of  confusion, 
dissociation,  hallucinations,  illusions,  unsystematized  or  feebly 
systematized  and  fragmentary  delusions,  are  all  present  in  a 
more  or  less  dominant  degree.  Years  ago.  Regis,  Christian, 
Anglade,  Macpherson,  Serieux,  Trepsat,  Dide,  and  others 
frankly  treated  this  mental  state  as  a  confusion,  and  this  is  an 
interpretation  which  I  have  myself  emphasized.    A  word  that 


THE    PSYCHOLOGIC    INTERPRETATION    OP    THE    SYMPTOMS     403 

Kraepelin  frequently  employs  in  describing  it  is  Zerfahrenheit, 
which  can  only  be  rendered  as  confusion  or  dissociation.  Admit- 
ing  freely  the  fact  of  confusion,  however,  it  soon  becomes 
evident  that  other  elements  are  present  which  demand  consider- 
ation. A  recognition  of  this  fact  is  of  the  utmost  importance. 
In  it  I  believe  lies  in  a  large  measure  the  explanation  of  some  of 
the  symptoms  which  seem  special  or  peculiar  to  dementia  prsecox. 
There  is  in  dementia  prsecox,  as  in  psychasthenia  and  in  hys- 
teria, a  diminution  in  the  activity  of  the  field  of  consciousness. 
Janet  has  expressed  this  idea  by  the  words  abaissement  du 
niveau  mental  (lowering  of  the  mental  level) .  I  have  myself  in 
various  papers  used  the  expression  "reduction  of  the  field  of 
consciousness"  to  convey  the  same  idea.  Weygandt,  in  discuss- 
ing the  psychology  of  the  mental  feebleness  in  dementia  prsecox, 
terms  the  end  process  of  the  disease  an  "apperceptive  dementia." 
I  do  not  think  that  much  is  gained  by  the  use  of  this  term.  Ac- 
cording to  Wundt,  apperception  is  the  special  process  by  which 
any  psychic  content  is  brought  to  clear  apprehension.  Into 
such  a  process  many  factors  must  enter — an  act  of  will,  the 
multiple  qualities  of  the  object  or  idea,  the  sensations,  emotions, 
and,  as  a  corollary,  the  impulses  to  which  these  necessarily  give 
rise.  Evidently  an  apperception  embraces  many  if  not  all  of  the 
factors  of  psychic  activity,  and  to  speak  of  an  apperceptive 
dementia  conveys  little  more  than  to  speak  of  dementia  as  a 
whole.  Further,  Weygandt,  it  is  to  be  noted,  applies  the  term 
only  to  the  end  process  of  dementia  prsecox.  Dementia  prsecox, 
as  we  all  know  and  as  has  already  been  emphasized,  is  not  a 
dementia  in  the  beginning,  but  only  in  the  more  advanced 
stages  of  the  disease.  The  term  "apperceptive  dementia"  is  not, 
therefore,  as  Jung  would  have  us  believe,  the  equivalent  of 
Janet's  term,  "depression  of  the  mental  level,"  and  if  we  strive  to 
modify  it  by  changing  it  into  "apperceptive  weakness"  little  is 


404  MENTAL    DISEASES 

gained  for  the  reasons  already  indicated.  Janet's  term,  which 
forms  the  keystone  of  his  conception  of  psychasthenia,  is  appHed 
to  the  dynamic  state  of  the  mind.  Psychasthenia  is  essentially  a 
state  of  psychic  adynamia.  This  is  exactly  the  idea  that  is  con- 
veyed by  the  term  "depression  of  the  mental  level."  It  is  a  con- 
dition of  the  mind  in  which  the  force,  the  intensity  of  its  proc- 
esses, is  lowered.  The  mind  in  such  a  state  is  like  a  fire  which, 
instead  of  burning  brightly,  is  reduced  to  embers,  it  may  be 
barely  glowing.  It  is  not  a  state,  however,  which  necessarily 
implies  disintegration,  deterioration,  or  dementia. 

The  existence  of  such  a  diminished  activity  of  the  field  of 
consciousness  can,  I  think,  be  admitted  without  hesitation. 
It  is  essentially  a  state  in  which  the  intensity,  the  vigor  of  the 
metabolic  processes  of  the  cortex  are  lessened;  just  such  a  state 
as  we  have  reason  to  believe  exists  in  psychasthenia.  When 
we  fully  appreciate  this  fact,  it  illuminates  much  in  the  symp- 
tomatology of  dementia  praecox  that  seems  obscure.  Let  us 
briefly  consider  some  of  the  symptoms.  The  slowness  of  speech 
and  poverty  of  thought  which  eventuate  in  mutism,  in  catatonia, 
in  stupor,  find  their  measure  of  explanation  in  an  adynamic  state. 
This  is  also  true  of  fixation  of  position,  stereotypy,  automatism, 
perseveration,  verbigeration.  Here  the  psychic  current,  which 
in  the  normal  mind  is  like  a  river  broad  and  deep  and  easily 
flowing,  has  been  reduced  to  a  shallow,  a  narrow,  and  a  monoto- 
nously trickling  stream.  Continuous  or  interrupted,  it  is  the  only 
thing  that  remains  in  the  field  of  consciousness.  Jung  and  others 
have  thought  that  its  monotony,  its  sameness,  is  due  to  the  fact 
that  the  entrance  of  other  associations  into  the  stream  is 
inhibited  or  blocked;  but  surely  dams,  obstructions,  are  not 
necessary  when  the  beds  of  the  tributary  streams  are  dry,  for 
we  must  remember  that  the  cortex  is  adjoiamic  as  a  whole. 
Again,  it  would  appear  that  the  adynamic  state  of  the  cortex 


THE    PSYCHOLOGIC    INTERPRETATION    OF    THE    SYMPTOMS     405 

does  not  involve  the  latter  equally  or  uniformly  and,  here  and 
there,  now  and  anon,  tributary  currents  join  what  is  left  of  the 
main  stream,  but  they  do  so  irregularly,  at  unusual  points, 
and  at  variance  with  the  orderly  sequence  of  normal  psychic 
processes.  We  find  that  instead  of  normal  associations,  mere 
sound  associations,  associations  of  coarse  resemblances,  and 
of  mere  contiguity  are  produced.  The  patient's  utterances  may 
be  confused,  disordered,  incoherent,  and  this  confusion  becomes 
more  marked  in  proportion  as  unrelated  complexes  force  them- 
selves into  the  field  of  consciousness.  Similar  phenomena  are, 
of  course,  equally  evident  when  the  patient  writes  letters  or 
attempts  to  express  himself  otherwise  on  paper. 

Again,  it  may  happen  that  the  field  of  consciousness  is  more 
greatly  reduced  dynamically  than  the  cortex  as  a  whole  or  than 
other  portions  of  the  latter.  Now,  it  is  probable  that  under 
normal  conditions,  the  activity  of  the  psychic  field  is  so  great 
that  it  diffuses  to  and  beyond  the  boundaries  of  consciousness, 
but  if  the  activity  of  the  psychic  field  is  relatively  diminished,  it 
results  dynamically  that  the  direction  of  the  diffusion  is  reversed, 
and  that  other  activities  now  flow  into  the  less  resistant  field. 
These  activities  probably  consist  of  complexes — of  groups  of 
associated  ideas — of  greater  relative  dynamic  power.  That 
they  necessarily  consist  of  complexes  which  have  been  re- 
pressed is  not  proved ;  that  they  sometimes  consist  of  complexes 
representing  wishes  and  things  desired  is  very  probable;  that 
they  also  represent  things  of  which  the  patient  stands  in  fear 
and  dread — complexes  that  are  painful — must  be  equally 
admitted. 

Negativism  probably  finds  its  explanation  in  the  fact  that 
every  impulse  or  feeling  is  represented  in  the  psychic  make-up, 
not  only  by  a  positive  complex,  but  also  by  its  exact  opposite; 
indeed,  it  is  probable  that  the  positive  complex  owes  its  existence 


406  MENTAL    DISEASES 

to  its  differentiation  from  the  general  psychic  material,  which 
thus  becomes  its  negative.  Now  it  would  seem  that  in  the 
lowered,  adynamic  state  of  the  field  of  consciousness,  the  posi- 
tive complex  cannot  find  expression;  of  necessity,  its  opposite, 
being  dynamically  stronger,  flows  into  the  field  and  finds  ex- 
pression. The  symptom  to  which  Bleuler  has  given  the  name 
ambivalence,  and  which  consists  in  the  tendency  of  the  patient 
to  give  expression  equally  to  opposing  impulses,  has,  it  would 
seem,  a  similar  explanation  and  need  not  detain  us.  It  may  be 
pointed  out,  however,  that  ambivalence  is  first  cousin  to  the 
symptom  of  indecision  of  the  typical  psychasthenic.  Again, 
the  abulia  of  catatonia  also  finds  a  ready  explanation  in  the 
adynamic  mental  state.  Further,  the  lack  of  inhibition,  im- 
pulsivity,  clownism,  mannerisms,  special  gestures  are  also 
rooted  in  the  same  condition.  The  particular  picture  presented 
by  a  given  case  at  a  given  time  is  obviously  linked  with  the  nature 
and  character  of  the  thought  or  psychic  process  that  is  persist- 
ing in  the  narrowed  field  of  consciousness.  It  is  not  surprising, 
for  instance,  that  a  tailor  should  make  recurring  movements  of 
sewing  or  a  woman  of  washing  or  wiping.  Our  Freudian  friends, 
however,  see  in  such  phenomena  the  persistence  of  repressed 
sexual  complexes. 

Finally,  the  activity  of  the  field  of  consciousness  may  become 
progressively  more  and  more  reduced,  until  no  outward  mani- 
festation of  any  psychic  activity  is  longer  evident;  under  such 
circumstances  stupor,  usually  a  catatonic  stupor,  supervenes. 

The  hallucinations  present  in  dementia  prsecox  are  due 
apparently  to  the  toxic  irritation  of  sensory  areas  of  the  cortex. 
The  excitation  resulting  breaks  in  an  unrelated  manner  into  the 
field  of  consciousness,  and  the  impression  produced  on  the  mind 
of  the  patient  is  that  of  a  sensation  of  extraneous  origin.  No 
wonder  that  the  patient  refers  the  noises  and  the  voices  to  the 


THE    PSYCHOLOGIC    INTERPRETATION    OF    THE    SYMPTOMS     407 

external  world.  In  such  a  case,  a  separate  portion  of  the  per- 
sonahty  addresses  itself  to  the  main  body  of  consciousness. 
Very  frequently,  indeed,  almost  always,  visceral  hallucinations 
and  often  sexual  hallucinations  are  also  present.  The  delusions 
— and  I  am  speaking  now  mainly  of  the  hebephrenic  and  cata- 
tonic forms — are  often  feebly  held,  commonly  disconnected 
and  disordered,  and  at  most  but  poorly  systematized.  What 
a  fertile  field,  what  a  wealth  of  repressed  sexual  complexes, 
they  have  yielded  to  the  psychanalyst  I  need  not  say.  That 
the  portion  of  the  cortex  irritated  by  the  toxin  may  be  other 
than  a  sensory  area  need  hardly  be  pointed  out.  In  this  way 
long  buried  associations — associations  which  have  no  relation 
to  the  subject  matter  of  the  field  of  consciousness — may  break 
in,  just  as  do  hallucinations.  That  such  associations  are  re- 
garded as  strangers  by  the  psyche  of  the  patient  can  also  be 
readily  understood.  At  other  times,  owing  to  the  low  dynamic 
tension  of  the  field  of  consciousness,  associations  long  dormant 
may  diffuse  into  the  field,  may  become  incorporated  with  the 
stream  of  thought,  and  may  greatly  modify  the  clinical  picture 
presented;  and  that  this  enters  into  the  explanation  of  such 
symptoms  as  impulsivity,  clownism,  special  gestures,  and  the 
like  is  extremely  probable. 

Bleuler,  in  his  article  on  dementia  prsecox  in  Aschaffenburg's 
Handbuch  der  Psychiatrie,  makes  a  most  elaborate  subdivision 
of  the  mental  symptoms,  a  subdivision  which  I  believe,  instead 
of  illuminating  the  subject  tends  to  add  to  its  obscurity.  '  I 
shall  not,  for  instance,  take  up  the  subject  of  autism  and  autistic 
thinking.  To  me  it  seems  quite  natural  that  a  patient  in  a  con- 
dition of  psychic  adynamia  and  suffering  with  numerous  vis- 
ceral or,  better,  coenesthetic  hallucinations,  should  be  taken  up 
with  his  own  world  of  self,  with  its  persecutions  or  its  expansions; 
which  last  our  Freudians  translate  into  wish  fulfilments.     I 


408  MENTAL   DISEASES 

cannot  understand,  however,  why  this  autism  should  be  given 
a  sexual  character  as  is  done  by  the  psychanalysts;  Freud,  for 
instance,  employs  in  its  stead  the  term  "auto-erotism";  but  it 
is  difficult,  for  that  matter,  to  understand  the  psychanalyst's 
attitude  at  all,  especially  when  as  Bleuler  says  the  only  treat- 
ment for  dementia  prsecox  is  the  psychic  treatment.  Inasmuch, 
he  tells  us,  as  the  symptomatology  of  the  disease  is  dominated 
by  the  complexes,  and  as  these  enable  us  to  penetrate  into  the 
psyche  of  the  patient,  we  should  expect  to  be  able  in  this  manner 
to  influence  them.  To  talk  of  psychanalysis  as  a  treatment 
for  a  patient  with  the  earmarks  of  a  defective  development, 
a  positive  Wassermann,  a  toxic  metabolism,  defensive  fer- 
ments, and  what  not,  is,  to  my  mind,  very  much  like  attempt- 
ing to  treat  a  broken  leg  or  a  typhoid  fever  by  the  same 
method. 

The  theory  of  a  reduction  of  the  field  of  consciousness  is  as 
applicable  to  the  explanation  of  hysteria  and  hypnosis  as  to 
dementia  prsecox,  and  yet  how  widely  these  affections  differ! 
This  difference  the  Freudian  theory  of  repressed  complexes 
fails  to  explain.  In  dementia  prsecox  the  depression  of  the 
cortical  activity  is  apparently  due  to  a  toxin,  a  defensive  fer- 
ment, the  result  of  the  ingress  into  the  blood  of  an  abnormal 
hormone  from  the  sex  glands  (see  p.  131).  It  is  not  improb- 
able, also,  that  the  nerve  substance  in  dementia  prsecox  is 
inherently  defective  and  feeble  in  resistance. 

Because  of  his  interpretation  of  dementia  prsecox  as  a  cleav- 
age or  fissuration  of  the  psychic  functions,  Bleuler  has  invented 
and  proposed  the  name  "schizophrenia,"  which  he  believes  to 
be  preferable  to  dementia  prsecox.  However,  as  we  have  seen, 
cleavages  and  fissurations  of  the  personality  are  not  confined 
to  dementia  prsecox.  They  occur  in  many  forms  of  mental 
disease,  as  well  as  in  the  neuroses;  in  my  judgment,  the  term 


THE    PSYCHOLOGIC    INTERPRETATION    OF    THE    SYMPTOMS     409 

being  of  such  general  significance  offers  no  advantages  over 
dementia  prsecox  and  should  be  rejected. 

It  is  exceedingly  probable  that  the  psychology  of  paranoia 
does  not  differ  radically  from  that  of  dementia  praecox.  That 
we  have  an  inherently  defective  individual  to  deal  with  is 
evidenced  both  by  his  heredity  and  by  his  person.  Further, 
that  even  in  paranoia  vera  the  patient  is  the  victim  of  abnormal 
feelings,  of  somatic  and  other  hallucinations,  is  a  matter  of 
clinical  observation.  That  he  has  a  morbid,  a  diseased  personal- 
ity cannot  be  gainsaid,  and  that  under  these  circumstances  he 
should  react  abnormally  to  his  experiences,  to  the  things  he 
actually  sees  and  hears,  is  not  surprising.  Indeed,  that  he 
should  regard  the  various  happenings  of  the  external  world  as 
bearing  directly  upon  himself  is,  it  would  seem,  exactly  what  we 
would  be  led  to  expect,  and  that  he  should  attribute  his  morbid 
and  illusory  feelings  to  the  same  source,  logically  follows. 
These  feelings  act  just  as  do  frank  hallucinations  and  address 
themselves  to  the  main  body  of  his  consciousness  as  a  separate 
portion  of  the  personality.  Further,  the  personaUty  is  diseased, 
sensitive,  and  taken  up  with  itself;  that  the  complexes  arising 
should  sooner  or  later  deal  with  persecution  is  again  not  sur- 
prising. The  change  of  personality,  the  transition  to  the  expan- 
sive phase,  is  probably  due  to  a  change  in  the  feelings,  the  coen- 
esthetic  sensations,  during  which  depressing  somatic  hallucina- 
tory feelings  give  way  to  fictitious  feelings  of  strength  and  power; 
perhaps  this  change  is  in  keeping  with  the  increasing  degenera- 
tion of  the  patient  and  consonant  with  retrogressive  changes 
in  his  metabolism. 

The  above  interpretation  seems  to  the  writer  much  more 
logical,  to  say  the  least,  than  that  offered  by  the  psychanalysts. 
The  fact  that  Freud  and  his  followers  see  nothing  but  the  libido 
has  led  them  to  interpret  paranoia  as  the  manifestation  of  an  un- 


410  MENTAL    DISEASES 

requited  homosexual  love;  if  a  paranoiac  slays  his  victim,  it 
is  not  because  the  latter  has  been  defaming,  ruining,  poisoning 
the  patient,  but  because  he  has  failed  to  return  the  homosexual 
love  of  the  patient!  Surely  the  facts  of  experience  flatly  contra- 
dict this  position.  Of  the  large  number  of  criminal  insane  which 
it  has  been  my  fortune  to  study  I  cannot  recall  a  single  instance 
in  which  such  an  explanation  would  apply.  Sexual  factors 
are,  it  is  true,  not  infrequent  in  female  paranoiacs,  but  they  are 
rarely  homosexual.  In  men  sexual  factors  are  much  less  fre- 
quent, and  in  the  experience  of  the  ^Titer  they  have  not  been 
homosexual.  The  patient  has  slain  his  ^^ctim  because  the 
latter,  by  his  machinations  and  persecution,  has  made  life 
impossible;  he  has  not  slain  him  because  of  unrequited  homo- 
sexual love.  When  sexual  factors  enter,  as  in  alcoholic  para- 
noia, the  patient  slays  the  vdie  or  the  mistress  whom  he 
beUeves  has  been  unfaithful.  I  know  of  no  parallel  instance 
in  which  the  victim  was  a  man. 

Finally,  when  we  analyze  the  primal  instincts  of  mankind, 
sexual  factors  do  not  assume  the  preponderating  importance 
which  the  Freudians  would  have  us  beheve.  The  primal  in- 
stincts may  be  enumerated  as  follows — first,  the  instinct  of  self- 
preservation;  second,  the  instinct  of  perpetuation  of  the  species; 
third,  the  instinct  of  communal  preservation  and  perpetuation. 

The  instinct  of  self-preservation  embraces  the  taking  of  food 
and  the  protection  of  the  person.  Complexes  deahng  with  these 
factors  are  found  among  the  insane  in  great  number.  We  have, 
on  the  one  hand,  the  great  mass  of  delusions  relating  to  food, 
poisons,  and  the  digestive  function,  and,  on  the  other,  the  de- 
lusions relating  to  physical  safety.  The  instinct  of  perpetua- 
tion of  the  species  embraces  the  complexes  deahng  ^-ith  the 
sexual  Ufe.  The  complexes  here  deal  first  w^th  hypochon- 
driac states  (see  p.  376) ;  second,  with  phobias  and  obsessions 


THE    PSYCHOLOGIC    INTERPRETATION    OF    THE    SYMPTOMS     411 

and  lastly,  mth  manifold  delusions  dealing  with  sexual  love. 
The  instinct  of  communal  preservation  and  perpetuation,  or 
as  it  had  best  be  termed,  the  instinct  of  herding  together — 
for  man  is  a  gregarious  animal — embraces  a  mass  of  complexes 
which  in  number  and  variety  greatly  exceed  those  of  the  other 
primal  instincts,  numerous  as  these  admittedly  are.  The  re- 
lations of  the  individual  to  the  community  in  which  he  lives 
are  multiple  and  comphcated  in  the  extreme.  It  would  alike 
be  a  hopeless  as  well  as  an  unnecessary  task  to  attempt  to  enu- 
merate them.  Further,  these  relations  are  exceedingly  close 
and  the  interchange  of  function  unceasing.  Lesions,  therefore, 
Taetween  the  individual  and  his  surroundings  are  relatively 
frequent.  The  workman  who  falls  behind,  who  is  jostled  or 
jibed  by  his  fellows  or  criticized  by  his  employer,  breaks  with 
his  surroundings  as  soon  as  the  idea  is  bred  in  his  mind  that  he 
is  being  persecuted.  That  such  ideas  may  be  evolved  under 
an  almost  infinite  variety  of  circumstances  is  a  matter  of  com- 
mon experience.  Gradually  the  breach  between  the  patient 
and  those  about  him  widens  until,  in  his  progressive  mental 
degeneration,  he  believes  that  he  is  not  of  them,  but  that  he  is 
of  special  birth,  and  creates  about  himself  a  world  of  his  o\mi, 
the  complexes  of  which,  as  we  have  seen,  become  fixed  and  in- 
accessible. 


PART   IV 

CHAPTER  I 

TREATMENT 

PREVENTION 

Under  the  head  of  treatment  it  is  important  first  to  consider 
prevention.  Insanity  when  once  established  offers  in  a  large 
nimiber  of  cases  so  little  prospect  of  improvement  or  recovery 
that  prevention  becomes  of  prime  importance;  it  is  in  this  field, 
rather  than  that  of  cure,  that  the  human  race  is  to  win  some  of 
its  greatest  victories.  Neuropathy,  which  is  but  another  word 
for  imperfect  and  deviate  development,  for  arrests  and  irregu- 
larities, for  pathologic  changes,  minute  or  gross,  is  due  to  causes 
active,  for  the  most  part,  in  the  ancestry.  These  causes  em- 
brace all  influences  which  impair  or  damage  the  organism; 
among  these  are  syphilis,  alcohol,  tuberculosis,  and  the  infec- 
tions and  intoxications  generally.  The  role  played  by  syphilis 
and  alcohol  is  of  overwhelming  importance;  so  great,  indeed, 
that  the  neuropathy  to  be  ascribed  to  other  causes  is  almost  a 
negligible  quantity. 

It  is  extremely  probable  that  alcohol  acts  not  only  by  damag- 
ing the  blood-vessels,  the  heart,  the  nervous  apparatus  and 
viscera  generally,  but  directly  influences  the  ductless  glands, 
the  pituitary,  the  thyroid,  the  testes,  and  ovaries.  We  know 
that  upon  the  integrity  of  these  glands  depends  the  harmonious 
and  full  development  of  the  organism.  That  they  should  be 
vulnerable  to  a  toxic  agent,  such  as  alcohol,  is  not  surprising; 

412 


TREATMENT  413 

and  it  is  probable  that  when  they  are  thus  damaged,  it  is  no 
longer  possible  for  the  organism  to  transmit  to  its  progeny  the 
same  potentiality  of  development  as  in  health. 

Syphilis,  as  we  know,  may  be  directly  transmitted  to  the 
offspring,  and  in  this  way  it  exercises  a  widespread  and  bane- 
ful influence;  idiocy,  imbecility,  high-grade  deficiencies  of  all 
kinds  may  be  traced  to  it.  However,  syphilis  also  acts  in  an- 
other way.  Like  alcohol,  it  damages  the  organism  as  a  whole ; 
weakness  and  degeneration  naturally  follow  in  its  wake.  Fi- 
nally, we  find  that  syphilis  and  alcohol  are  very  frequently 
associated,  and  in  their  combined  action  we  have  a  most 
potent  cause  for  impairment,  an  impairment  which  we  have 
reason  to  believe  persists  through  generations. 

Tuberculosis,  the  various  acute  infectious  diseases,  as  well 
as  the  intoxications  other  than  alcohol,  may  play  a  role  in  the 
weakening  of  stocks,  but  if  so  their  role  is  less  apparent.  Tu- 
berculosis is,  it  is  true,  met  with  in  a  large  number  of  the 
insane,  notably  in  dementia  prsecox,  but  it  is  extremely  likely 
that  this  vulnerability  is  secondary  to  a  weakened  power  of 
resistance  of  the  organism,  and  is  not  of  itself  a  primary  cause 
As  regards  the  acute  infections,  there  is  no  direct  evidence  that 
they  exercise  deteriorating  effects  transmissible  from  parent 
to  offspring.  In  intoxication  by  morphin,  cocain,  and  other 
drugs  the  number  of  cases,  compared  with  those  of  chronic 
alcoholic  abuse,  is  so  small  that  they  play  no  obvious  or  im- 
portant role  in  the  production  of  inherited  neuropathy.  It  is 
syphilis  and  alcohol  which  stand  prominently  forth  as  the 
great  causes,  and  it  is  in  their  prevention  that  the  great  hope 
of  the  future  lies. 

Physicians  should,  of  course,  advise  against  marriage  when 
either  party  has  a  neuropathic  ancestry  or  is  the  victim  of 
an  inherited  neuropathy.    Unfortunately,  the  advice  is  only 


414  MENTAL    DISEASES 

infrequently  accepted.  If  it  is  rejected,  we  should  at  least 
urge  delay  until  adult  life  has  been  well  entered  and  the  like- 
lihood of  an  inherited  psychosis  manifesting  itself  diminished. 
Marriage  is  sometimes  advocated  by  physicians  because  in- 
sanity is  more  conunon  in  the  unmarried,  but  it  should  never 
be  advocated  under  the  conditions  we  have  just  considered. 
Again,  if  insanity  is  already  estabUshed  it  is  bad  for  the  patient, 
especially  if  the  patient  is  a  woman.  Finally,  marriage  between 
cousins,  if  the  stock  bears  a  neuropathic  strain,  is  especially 
dangerous.  However,  in  the  absence  of  such  strain,  in  the 
presence  of  a  clear  famih'  histon,',  there  can,  on  physiologic 
grounds,  be  no  objection.  The  results  of  the  interbreeding  of 
domestic  animals  do  not,  to  say  the  least,  justify  an  opposite 
opinion.  However,  in  the  human  race,  a  heredity  without  taint 
appears  to  be  the  exception. 

Among  the  expedients  that  are  frequently  advocated  for  the 
prevention  of  insanity  is  sterilization,  carefully  regulated  by 
law.  It  would  appear  that  there  is  no  sound  or  ethical  objection 
to  its  apphcation  in  the  case  of  patients  who  are  repeatedly 
under  the  care  of  institutions  for  confirmed  psychoses,  or  who 
are  morons,  mattoids,  or  confirmed  crimuials.  The  baneful 
effect  on  the  commimity  by  the  free  propagation  of  the  degen- 
erate and  criminal  classes  can  with  difficulty  be  estimated. 
Much  can,  however,  be  accompHshed  by  the  isolation  of  these 
imfortunates.  In  the  case  of  the  chronic  insane  and  the  de- 
fectives, the  isolation  may  be  made  practically  permanent; 
unfortunately,  this  is  not  the  case  with  the  criminal. 

Time  and  again  the  physician  is  confronted  udth  the  problem 
of  the  education  and  training  of  a  child,  ner^^ous  it  may  be,  or 
the  \'ictim  of  a  neuropathic  heredity.  Eft'orts  should  be  made 
to  guard  the  child  hygienically  from  its  early  infancy.  As  far 
as  possible  the  exhausting  influence  of  long-continued  internal 


TREATMENT  415 

disturbances,  of  repeated  childhood  infections,  of  attacks  of 
convulsions,  should  be  combated.  As  the  child  approaches 
the  years  of  school  great  care  should  be  exercised  to  prevent 
undue  mental  strain.  The  child  should  first  be  submitted  to  a 
thorough  psychologic  examination,  preferably  by  the  Binet- 
Simon  system,  and  the  results  used  as  a  guide  in  the  future 
course  of  education.  It  is  wise,  also,  to  repeat  this  examina- 
tion at  intervals  of  a  year  or  two,  not  so  much  to  determine 
the  existing  state  of  the  child's  training,  as  to  determine 
whether  there  has  been  any  increase  in  the  basic  mental  power. 

In  devising  a  plan  of  education,  we  should  remember  that 
nervous  children  become  exhausted  very  readily,  both  mentally 
and  physically.  As  far  as  possible  school  tasks  should  be  Hm- 
ited  to  the  school-room  and  the  work  should  be  interspersed 
with  play,  with  diversion  in  the  open  air.  The  work  itself 
should  be  presented  in  a  concrete  form,  should  not  necessitate 
abstract  conceptions,  and  should  be  made  humanly  interesting 
and  attractive.'  Thus,  the  child  should  be  taught  elementary 
natural  history  from  the  actual  objects,  drawing,  molding  in 
clay,  geography  from  large  and  small  globes,  physics,  and 
other  natural  branches  with  simple  apparatus  and  models.  If 
taught  to  read,  the  subject  matter  should  be  of  such  a  charac- 
ter, as  appeals  to  a  child,  and  may  be  made  the  basis  of  a  story 
by  the  teacher.  Later,  manual  training  and  more  serious 
mental  work  should  be  attempted.  The  teaching  should 
always  include  something  which  experience  has  taught  appeals 
to  the  child. 

The  nervous  child  is  apt  to  be  very  sensitive,  and  care  should 
be  taken  not  to  make  it  self-conscious;  nothing  should  be  said 
or  done  which  demeans  the  child  in  its  own  eyes,  or,  least  of 
all,  in  the  eyes  of  its  comrades.  That  such  a  child  stands 
being  teased,  jibed,  or  made  fun  of  very  badly  is  a  common 


416  MENTAL    DISEASES 

experience.  While  this  care  is  being  exercised,  the  wholesome 
discipline  of  teaching  the  child  to  do  its  part  at  school,  of  educat- 
ing it  to  a  sense  of  its  responsibility  to  the  teacher,  should  be 
faithfully  carried  out.  The  child's  spontaneity  should  not  be 
suppressed,  but  it  should  be  encouraged  to  do  its  work  as  best 
it  can.  It  should  be  taught  gradually  to  rely  upon  itself.  Its 
initiative  and  will  power  should  be  strengthened,  but,  at  the 
same  time,  it  should  be  taught  self-control.  The  latter  is 
perhaps  the  most  difficult  task  before  the  teacher.  Coddling 
and  indulgence  must,  of  course,  be  avoided.  On  the  other  hand, 
excessive  work  is  bad;  fatigue  and  the  habit  of  inattention  be- 
come established;  after  all  it  depends  upon  the  teacher  how 
far  to  go.  In  this  connection  should  be  mentioned  the  bad 
effect  of  the  severe  examinations  held  periodically  in  most 
schools. 

Care  should  be  taken  that  the  summer  vacations  are  spent, 
if  possible,  in  the  country,  and  that  physical  exercise  and  the 
companionship  of  wholesome  playmates  are  not  lacking.  In 
other  words,  the  life  should  be  made  as  normal  as  possible. 

As  the  years  of  puberty  are  approached,  the  fact  should  be 
borne  in  mind  that  during  this  time  the  child  is  less  capable  of 
doing  fatiguing  work,  and  especially  is  this  true  of  girls  during 
the  menstrual  epoch.  Masturbation  should  when  discovered 
be,  if  possible,  corrected. 

If  the  child  remains  well,  grows  up,  and  the  time  for  choosing 
an  occupation  approaches,  the  physician  should  advise  against 
any  calling  involving  much  strain.  Usually  children  of  a 
neuropathic  heredity  are  unfitted  for  a  professional  career. 
Such  a  career  necessitates  hard  mental  application,  with  severe 
examinations  during  the  student  period  and  usually  entails  a 
life  of  more  or  less  tension  and  strain  afterward.  On  general 
principles,  work  on  a  farm,  the  occupation  of  florist  or  fruit 


TREATMENT  417 

grower,  is  greatly  to  be  preferred.  However,  as  far  as  practi- 
cable, the  inclinations  of  the  individual  must  be  followed.  The 
depression  caused  by  a  hated  occupation,  one  which  prom- 
ises nothing  for  the  future,  and  in  which  the  man  feels  that  he 
is  out  of  place,  often  exercises  a  most  disastrous  effect. 

EXTRAMURAL    TREATMENT 

A  knowledge  of  the  management  and  treatment  of  mental 
disorders  on  the  part  of  the  practising  physician  is  inseparable 
from  his  calling.  It  is  invariably  the  general  practitioner  who 
sees  the  patient  first,  and  it  devolves  upon  him  to  decide  not 
only  upon  the  immediate  care  and  treatment,  but  also  upon 
the  eventual  course  to  be  pursued. 

Naturally  the  first  object  is  to  insure,  as  far  as  possible,  the 
safety  of  the  patient  and  of  those  about  him.  Almost  imme- 
diately there  comes  up  the  question  as  to  commitment.  In  a 
large  number  of  cases  this  question  almost  decides  itself.  This 
is  the  case,  for  instance,  in  acute  mania  and  in  other  forms  of 
mental  disturbance  with  excitement,  and  also  in  most  cases  of 
delusional  lunacy.  Commitment,  however,  is  attended  by  a 
serious  responsibility  for  the  practitioner,  and  it  is  necessary 
for  him  to  act  cautiously  and  to  bear  in  mind  a  number  of  im- 
portant points.  In  the  first  place,  he  should  never  allow  him- 
self to  be  hurried  as  to  commitment.  He  should  always  insist 
upon  sufficient  time  to  make  a  proper  examination  and  at 
least  an  approximate  diagnosis.  Even  in  cases  attended  by 
marked  excitement  should  he  observe  this  rule.  It  is  exceed- 
ingly annoying,  for  instance,  to  a  physician  to  find  that  he  has 
committed  a  patient  to  an  asylum  who  was  merely  actively 
delirious,  and  in  whom  the  delirium,  as  is  usually  the  case,  has 
subsided  in  a  few  days — perhaps  shortly  after  the  admission 
into  the  asylum.     In  such  an  instance  the  friends  and  relatives 

27 


418  MENTAL    DISEASES 

who  were  active  in  insisting  upon  commitment  may  be  the  very 
ones  to  lay  blame  upon  the  physician — to  accuse  him  of  having 
acted  hastily  and  of  having  needlessly  placed  the  stigma  of 
insanity  upon  the  patient  and  the  patient's  family.  It  is 
necessary,  therefore,  that  the  physician  should  be  able  to  make 
a  differential  diagnosis  between  a  mere  dehrium  and  a  mania. 
A  delirium  has  a  duration  of  a  few  hours,  several  days,  or  less 
frequently,  a  week  or  two.  A  mania,  on  the  other  hand, 
has  a  duration  extending  over  three  or  more  months.  (See 
p.  92.)  It  is  of  importance  always  to  act  dehberately  and  to 
avoid  haste  unless  the  facts  of  the  ilhiess  from  which  the  patient 
is  suffering  are  very  evident  and  urgency  be  great.  Certainly, 
in  all  cases  in  which  the  patient  is  neither  dangerous  nor  violent, 
the  physician  should  take  sufficient  time  to  satisfy  himself 
thoroughly,  first,  as  to  the  actual  existence  of  insanity,  and, 
second,  as  to  the  ad\asabifity  of  commitment.  The  physician 
should  invariably  decline  to  commit  whenever  any  doubt,  no 
matter  how  slight,  arises.  The  legal  responsibiUty  of  phys- 
icians in  making  commitment  should  always  be  borne  in  mind. 

The  patient,  having  been  examined  and  the  diagnosis  of 
insanity  having  been  made,  the  physician  should  next  consider 
whether  the  patient  is  dangerous  to  himself  or  others.  If  so, 
commitment  should  be  ad\'ised.  Second,  other  things  equal, 
commitment  should  be  ad^^sed  when  it  is  e\'ident  that  the 
treatment  cannot  be  carried  on  satisfactorily  outside  of  an 
institution. 

It  becomes  evident  that  cases  of  insanity  separate  them- 
selves natm-ally  into  two  great  groups,  the  intramural  and  the 
extramural  cases.  While  the  intramural  cases — those  requir- 
ing commitment — constitute  by  far  the  larger  number,  a  little 
reflection  vnW  convince  us  that  the  number  of  extramural  cases 
is  by  no  means  small.  Further,  even  the  cases  which  become 
intramural  are  in  the  hands  of  the  practitioner  for  a  shorter  or 


TREATMENT  4:19 

longer  period  previous  to  commitment.  Let  us  briefly  turn 
our  attention  first  to  this  group  of  cases. 

As  soon  as  the  decision  to  commit  has  been  reached,  the 
patient  should  be  carefully  watched.  This  duty  may  devolve 
upon  the  members  of  the  family,  or  it  may  be  necessary  for  the 
time  being  to  employ  a  trained  nurse,  though  the  latter  course 
is  usually  not  necessary.  The  transfer  to  the  asylmn  should  be 
accomphshed  as  soon  and  as  expeditiously  as  possible.  In  the 
interval  no  treatment  whatever  should  be  instituted.  Only 
exceptionally  is  it  necessary  to  give  some  sedative  to  moderate 
or  aUay  excitement.  Here  the  rule  should  be  foUowed  to  give 
the  milder  drugs;  that  is,  those  which  are  not  attended  by  much 
depression.  Drugs  had  best  be  avoided  or  resorted  to  only  in 
emergency,  as,  for  example,  when  we  have  to  choose  between 
their  use  and  gross  physical  restraint. 

The  cases  which  cannot  or  should  not  be  committed — that 
is,  the  extramural  cases — comprise  the  various  transient 
deliria,  mild  melancholia,  some  cases  of  dementia  prsecox, 
mild  and  harmless  paranoia,  the  neurasthenic-neuropathic 
insanities,  and  some  forms  of  dementia,  such  as  mild  senile 
dementia.  Let  us  turn  our  attention  to  the  treatment  of  this 
group  of  cases. 

The  delirium  which  accompanies  the  ordinary  febrile  affec- 
tions, .the  various  exanthemata  and  infectious  diseases,  rarely 
requires  special  treatment.  The  treatment  and  management 
of  the  underlying  disease,  as  a  rule,  alone  concerns  the  phys- 
ician. There  are,  however,  other  deliria  which  it  is  incumbent 
upon  the  physician  to  treat;  these  are  dehrium  grave,  which 
is  fortunately  very  rare,  the  postfebrile  dehria  (the  dehria  which 
come  on  during  the  convalescent  periods  of  infectious  diseases, 
such  as  typhoid  fever,  grip,  erysipelas,  pneumonia,  etc.),  and 
the  deliria  which  follow  the  abuse  of  certains  poisons,  such  as 


;i20  MENTAL   DISEASES 

alcohol.  The  management  of  a  deUrium  should  be  conducted 
upon  general  principles.  We  should  bear  in  mind  that  we 
have  to  deal  with  two  underlying  pathologic  factors — first, 
nervous  exhaustion,  and,  second,  the  toxin  of  some  infectious 
disease  or  some  poison  introduced  from  without,  such  as  alco- 
hol. The  treatment  resolves  itself  into  the  following  indica- 
tions: first,  the  elimination  of  the  poison;  second,  the  main- 
tenance of  the  nervous  strength;  and  third,  the  allaying  of 
the  excitement  so  far  as  may  be  necessary.  As  much  as  pos- 
sible these  indications  must  be  met  promptly  and  simultane- 
ously. The  means  at  our  command  consist  in  the  adminis- 
tration of  liquids  in  large  quantities,  the  free  use  of  baths,  the 
free  administration  of  nourishment,  and  the  administration, 
when  necessary,  of  cardiac  stimulants  and  nervous  sedatives. 
Liquids,  of  course,  act  as  diuretics,  while  the  action  of  the  skin 
is  stimulated  by  the  bathing.  If  fever  be  present,  cold  spong- 
ing or  other  forms  of  cold  bathing  are  applicable;  if,  however, 
the  delirium  be  afebrile,  as  is  usually  the  case  in  the  postin- 
fectious and  toxic  deliria,  the  most  efficient  form  of  hydro- 
therapy is  a  prolonged  warm  immersion  bath.  The  tempera- 
ture of  such  a  bath  should  range  from  90°  to  95°  F.  However, 
in  ordinary  household  practice  a  warm  immersion  bath  can 
only  exceptionally  be  used.  It  is  not  practicable,  as  a  rule, 
to  carry  a  struggling  patient  to  a  bathroom  and  subject  him 
to  the  strain  of  the  necessary  handling  and  manipulation. 
Much  more  serviceable  and,  in  some  cases,  more  efficacious  is 
the  wet  pack.  This  should  be  given  in  the  ordinary  way,  save 
that  the  sheet,  instead  of  being  dipped  in  cold  water,  should 
be  dipped  in  warm  water.  The  patient,  having  been  thor- 
oughly and  closely  wrapped,  blankets  are  appHed  over  the  sheet 
and  the  patient  allowed  to  remain  in  the  pack  for  about  an 
hour.  As  a  rule,  profuse  diaphoresis  results,  with  a  marked 
diminution  of  the  excitement.     In  delirium  of  marked  severity, 


TREATMENT  421 

however,  both  the  wet  pack  and  the  immersion  bath  have 
serious  drawbacks.  The  necessary  manipulations  add  greatly 
to  the  confusion  and  excitement  from  which  the  patient  is 
suffering,  and  may  in  this  way  greatly  aggravate  the  exhaustion. 
Further,  neither  the  wet  pack  nor  the  immersion  bath  should 
be  repeated  too  often.  Especially  is  this  caution  necessary  in 
cases  in  which  the  delirium  is  somewhat  prolonged  and  in  cases 
in  which  exhaustion  is  a  marked  factor.  The  sweating  from 
the  wet  pack  should  in  this  connection  be  especially  borne  in 
mind. 

It  is  of  the  utmost  importance  in  many  cases,  especially  if 
the  delirium  be  violent  and  the  patient  be  expending  much 
strength  in  his  struggles,  to  administer  sedatives.  No  well- 
founded  objection  can  be  made  to  their  judicious  employment, 
for  the  quiet  and  sleep  produced  are  of  the  utmost  benefit. 
As  a  rule  the  milder  hypnotics  prove  efficacious,  and,  if  the 
patient  can  be  induced  to  swallow,  a  dose  of  trional,  15  or  20 
grs.,  can  be  administered;  or,  better  still,  trional  with  sul- 
phonal,  15  or  20  grs.  of  the  former  with  10  or  15  grs.  of  the  latter. 
Occasionally  medinal  (veronal  sodium),  10  grs.,  or  veronal, 
10  grs.,  with  sulphonal,  15  grs.,  has  a  very  happy  effect.  Lumi- 
nal, which  has  of  late  years  been  added  to  our  armamentarium 
and  which  belongs  to  the  veronal  group,  often  proves  efficacious 
in  so  small  a  dose  as  3  grs.,  and  is  perhaps  the  sedative  of  election. 
If  the  excitement  be  very  great,  and  the  struggling  of  the 
patient  severe,  the  question  arises  whether  some  form  of  hypo- 
dermic medication  should  not  be  practised.  In  this  connec- 
tion, hyoscin  presents  itself.  Hyoscin  has  the  disadvantage 
of  being  somewhat  uncertain  in  its  action,  and  while  by  many 
writers  scopolamin  is  considered  to  be  identical  with  hyoscin, 
in  the  experience  of  the  writer  scopolamin  is  a  much  more  cer- 
tain remedy.  In  doses  of  ^h  or  y^ir  of  a  grain  it  acts  speedily 
and  promptly  in  allaying  excitement.     The  writer,  however, 


422  MENTAL    DISEASES 

rarely  uses  scopolamin  alone,  but  usually  together  with  a  small 
dose  of  morphin.  For  instance,  a  hypodermic  injection  of  rhs  of 
a  grain  of  scopolamin  with  |  of  a  grain  of  morphin  has  a  prompt 
sedative  effect,  without  there  being  any  appreciable  cardiac  or 
nervous  depression.  The  two  drugs,  scopolamin  and  morphin, 
act  synergetically,  one  reinforcing  the  other,  only  a  small  dose 
of  each  being  necessary.  Many  patients  after  such  a  hypodermic 
injection  permit  of  free  manipulation.  A  bath  or  wet  pack, 
which  before  such  a  hypodermic  injection  could  only  be  given 
with  the  greatest  difficulty,  can  now  be  given  with  ease.  Such 
a  patient  is  also  much  more  amenable  to  other  procedures, 
such  as  the  giving  of  an  enema  or  the  administration  of  liquids 
by  the  mouth.  If  a  repetition  of  the  dose  is  necessary,  the 
amount  of  the  scopolamin  should  be  reduced  to  2^  of  a  grain. 
An  exceedingly  valuable  remedy  for  hypodermic  use  is  luminal 
sodium.  It  is  perhaps  the  most  useful  of  all  and  seems  to  be 
entirely  free  of  objection.  It  is  also  very  soluble  and  the  ad- 
ministration of  3  grains  is  usually  followed  in  some  twenty 
minutes  by  marked  sedation  and  without  any  appreciable 
influence  upon  the  pulse  or  respiration. 

In  considering  remedies  which  are  of  value  in  bringing  about 
rapid  sedation  we  should  be  mindful  of  paraldehyd.  This  is  a 
remedy  which  produces  sleep  almost  immediately,  certainly 
within  ten  or  fifteen  minutes,  and  this,  too,  without  producing 
the  slightest  cardiac  or  respiratory  depression.  Its  disgusting 
odor  and  offensive  taste  are  its  principal  objections,  and  j'et 
many  patients,  especially  male  patients  suffering  from  alcoholic 
delirium,  can  be  induced  to  take  the  drug  if  it  be  suspended  in 
whisky.  In  cases  of  great  excitement  a  dram  may  be  admin- 
istered with  prompt  effect.  Unfortunately  the  sleep  it  produces 
lasts  only  from  two  to  three  hours.  Paraldehj-d,  however,  may 
prove  to  be  a  valuable  adjuvant  when  scopolamin  and  morphin 
or  other  remedies  have  been  given  in  small  doses  and  have 


TREATMENT  423 

been  ineffectual  in  producing  sleep,  or  when  trional  and  sul- 
phonal  have  been  given,  and  the  remedies,  acting  slowly,  fail 
of  effect.  Under  such  circumstances  paraldehyd  hastens  the 
sleep,  while  the  other  remedies,  already  administered,  prolong 
it.  In  the  choice  of  hypnotics,  and  the  method  of  their  admin- 
istration, we  must  be  guided  by  general  principles.  If  used  at 
all,  they  should  be  used  promptly  and  in  sufficient  dose. 

Delirium  is  fortunately  of  relatively  short  duration,  and 
questions  as  to  the  administration  of  nourishment  rarely  become 
acute.  However,  if  there  be  clanger  of  exhaustion,  measures 
should,  so  far  as  possible,  be  instituted  to  maintain  the  strength 
of  the  patient;  liquid  food,  milk,  eggs,  beef  preparations  of 
various  kinds  should  be  administered,  and,  if  the  loss  of 
strength  be  great,  heart  tonics  or  stimulants  may  be  resorted 
to.  In  this  connection,  strychnin,  digitalis,  strophanthus, 
nitrogh^cerin,  cocain,  camphor,  and  perhaps  pituitrin  should  be 
borne  in  mind.  As  far  as  possible  in  urgent  cases  these  remedies, 
because  of  the  more  prompt  and  definite  effect,  should  be  given 
hypodermically.  In  certain  cases,  also,  alcohol  should  be  ad- 
ministered. This  had  best  be  given  with  nourishment;  for 
example,  with  milk. 

As  we  have  seen,  it  occasionally  happens  that  in  the  post- 
febrile period  of  one  of  the  infectious  diseases,  for  example, 
typhoid  fever,  instead  of  a  delirium  supervening,  the  patient 
passes  into  a  condition  of  confusion;  as  a  rule,  this  confusion  is 
active  in  character.  (See  page  49.)  As  in  delirium,  there  enter 
into  the  causation  of  confusion  two  factors :  first,  the  toxins  of 
the  infection,  and,  second,  persistent  exhaustion.  Confusion 
(or  confusional  insanity)  differs  from  delirium  not  only  in  the 
less  violent,  less  acute  character  of  its  symptoms,  but  also  in  its 
duration.  As  a  rule,  when  once  established,  it  lasts  many 
months — three  or  four  or  more. 

In  the  treatment  of  confusion,  we  are  to  be  guided  by  prin- 


424  MENTAL    DISEASES 

ciples  similar  to  those  just  discussed  in  speaking  of  delirium, 
but  we  are  especially  confronted  by  the  all-important  fact  of 
the  long  duration  of  the  illness.  If  the  means  of  the  patient 
permit,  proper  arrangements  should  be  made  for  his  care  out- 
side of  an  asylum.  The  entire  treatment  can  in  such  case  be 
conducted  at  his  own  home  or  at  some  other  suitable  establish- 
ment. Such  a  patient  will  require  at  least  two  trained  nurses. 
The  question  of  commitment  depends  entirely  upon  the  fact 
whether  the  patient  can  be  cared  for  satisfactorily  and  properly 
outside  of  the  asylum.  In  any  event,  it  is  wise,  because  of 
his  profound  exhaustion,  to  place  the  patient  in  bed.  Even 
cases  of  mild  confusion  do  better  when  the  plan  of  bed  treat- 
ment is  carried  out.  As  a  rule,  cases  of  confusion  are  quite 
manageable.  Food  can  usually  be  administered  without  much 
difficulty,  the  patients  also  permit  themselves  to  be  handled 
and  bathed  readily,  and  it  is  also  possible,  especially  during 
the  period  of  convalescence,  to  einploy  massage.  As  far  as 
possible  "rest  methods"  should  be  instituted.  Full  feeding, 
as  in  neurasthenia,  should  be  carried  out;  milk,  eggs,  and 
other  food  should  be  given  in  large  quantities. 

Medication  should  be  avoided  or,  at  least,  should  be  used 
only  when  really  required,  as,  for  example,  when  there  is  unusual 
excitement.  The  mere  length  of  the  duration  of  the  affection 
is  a  warning  against  the  long-continued  use  of  drugs.  This 
applies  also  to  the  use  of  tonic  and  supporting  remedies.  As  a 
rule,  medicines  are  required,  if  at  all,  only  from  time  to  time. 
General  principles  and  common  sense  must  guide  the  practi- 
tioner, for  no  hard-and-fast  rule  can  be  laid  down.  As  regards 
hypnotics,  it  is  a  good  plan  to  change  from  one  to  the  other,  and 
then  again  to  omit  them  altogether.  Especially  is  this  the 
case  when,  as  in  puerperal  confusion  (see  page  328),  the 
patient  is  sometimes  actively  disturbed  for  many  weeks  or 
months.     Under   these   circumstances  we  should  be  content 


TREATMENT  425 

if,  during  critical  periods,  the  patient  secures  from  four  to  six 
hours'  sleep  out  of  the  twenty-four;  a  sleep  of  eight  or  nine 
hours'  duration  is  not  necessary. 

Now  and  then,  as  we  have  seen,  instead  of  the  patient  passing 
into  a  condition  of  confusion,  stupor  may  ensue  during  the 
convalescent  period  of  the  infectious  diseases.  Here,  again, 
the  question  of  commitment  is  one  of  practicability.  If  the 
patient  has  the  means  to  employ  two  skilled  attendants,  he 
can  be  safely  cared  for  in  his  own  home  or  in  some  other  suitable 
place.  A  treatment  is  to  be  carried  out  similar  to  that  of  con- 
fusion. Like  confusion,  stupor  is  of  long  duration.  Many 
weeks,  often  months,  pass  by  before  convalescence  is  estab- 
lished, and  during  this  time  as  much  food  as  possible  must  be 
given,  for  the  treatment  is  essentially  supporting  in  character. 
Feeding  does  not  usually  offer  much  difficulty.  Frequently 
it  is  possible  to  administer  very  large  amounts  of  milk  and  raw 
eggs.  Now  and  then,  however,  the  stupor  is  so  profound  as  to 
necessitate  forcible  feeding;  that  is,  feeding  by  means  of  the 
nasal  or  stomach-tube.  Drugs  are  rarely  necessary.  Massage 
may  be  used  during  the  convalescence. 

In  confusion  and  stupor  the  circumstances  which  usually 
obtain  do  not  differ,  so  far  as  nursing  and  medical  attendance 
are  concerned,  from  those  of  a  case  of  some  continued  fever.  The 
patient  is,  as  a  rule,  not  violent  and  can  readily  be  controlled. 
Two  nurses,  one  relieving  the  other,  are  necessary,  as  it  is  not 
safe  to  leave  the  patient  alone.  Because  of  the  long  duration 
of  these  affections,  the  expense  involved  by  trained  nursing 
and  medical  attendance  outside  of  an  asylum  necessitates,  in 
many  instances,  the  commitment  of  the  patient. 

The  consideration  of  the  treatment  of  delirium  and  its  con- 
geners, confusion  and  stupor,  serves  the  purpose  of  illustrating 
the  basic  principles  underlying  the  treatment  of  mental  and 
nervous  disorders  generally.      These  embrace,  to  a  greater  or 


426  MENTAL   DISEASES 

less  degree,  the  simple  physiologic  procedures  of  the  rest-cure. 
As  in  simple  neurasthenic  states,  exhaustion  is  one  of  the 
dominant  factors  of  mental  disorders.  Rest — radical,  absolute 
rest  in  bed — should,  especially  in  the  acute  affections  or  in  the 
beginning  periods  of  the  more  prolonged  disorders,  be  insti- 
tuted whenever  practicable.  In  addition,  the  patient  should 
be  full  fed.  According  to  circumstances,  a  generous  mixed 
diet  should  be  instituted,  to  which  should  be  added  milk  and 
raw  eggs  in  liberal  quantities.  Bathing,  tepid  or  warm, 
between  blankets,  should  be  practised  daily,  and  the  absence 
of  exercise  should  be  compensated  by  daily  massage.  Free 
elimination  should  be  encouraged  by  the  ingestion  of  liquids 
and  by  maintaining  a  regular  action  of  the  bowels.  In  other 
words,  the  principles  to  be  applied  consist  of  rest,  feeding, 
exercise  without  the  expenditure  of  energy;  i.  e.,  massage 
and  the  securing  of  free  elimination.  As  we  shall  see,  these 
principles  require  modification  according  to  the  nature  of  the 
affection  which  presents  itself. 

Of  the  manic-depressive  group,  melancholia  is  the  only 
one  that  can  be  managed  outside  of  an  asylum,  and  this  only 
when  the  melancholia  is  relatively  mild  in  degree  and  under 
special  circumstances.  A  case  of  typical  acute  mania  obvi- 
ously cannot  be  treated  outside  of  an  asylum.  This  is  also 
true  of  the  larger  number  of  the  milder  cases  of  mania;  i'.  e., 
those  termed  hjqpomania.  Hjipomania  often  presents  numer- 
ous practical  difficulties;  while  the  patient  is  expansive  and 
exalted,  his  excitement  may  not  be  so  great  as  to  lead  his 
friends  to  suspect  that  he  is  insane.  He  is,  as  a  rule,  boister- 
ous and  loud  in  his  conduct,  often  extravagant  and  reckless. 
Often  he  drinks  to  excess,  and  is  frequently  guilty  of  erotic  and 
immoral  conduct;  and  yet,  while  these  symptoms  are  present. 


TKEATMENT  427 

the  degree  of  lucidity  of  mind  may  be  so  great  as  to  lead  the 
friends  of  the  patient  to  scout  the  idea  of  insanity.  Such 
patients  are  usually  exceedingly  difficult  to  treat,  because  they 
reject  the  proffered  assistance  of  both  physician  and  nurses. 
If  the  symptoms  become  more  pronounced,  and  the  friends  of 
the  patient  are  finally  convinced  that  their  relative  is  insane, 
and  commitment  is  agreed  upon,  it  not  infrequently  happens 
that  the  patient,  after  commitment,  takes  legal  steps  to  secure 
his  release.  Quite  often,  too,  misguided  friends  and  others 
espouse  his  cause,  and  much  personal  annoyance  and  incon- 
venience may  be  caused  the  physician  and  the  members  of  the 
family  who  were  active  in  bringing  about  the  commitment. 
Cases  of  hypomania,  especially  when  occurring  in  women, 
sometimes  present  almost  insurmountable  difficulties,  for  at 
times  they  can  neither  be  committed  nor  can  they  be  success- 
fully controlled  outside  of  the  asylimi. 

It  is  usually  impossible  to  persuade  a  hypomanic  patient  to 
remain  in  bed.  If,  however,  this  can  be  accomplished  much 
may  be  gained.  Warm  bed  bathing,  the  warm  pack,  may  be 
instituted,  as  well  as  massive  feeding.  Massive  feeding  of  itself 
exercises  a  sedative  influence  and  sometimes  to  a  pronounced 
degree.  As  a  rule,  however,  rest  methods  are  impracticable 
over  very  extended  periods,  but  during  the  time  the  patient 
is  in  bed  she  gets  accustomed  to  the  presence  of  her  nurses 
and  to  some  extent  forms  the  habit  of  jdelding  to  their  domi- 
nation; thus  the  subsequent  care  and  control  of  the  case  is 
made  less  difficult. 

As  above  stated,  of  the  manic-depressive  group  of  mental 
affections  the  milder  forms  of  melancholia  are  the  ones  which 
are  best  adapted  to  extramural  treatment.  If  the  patient  be 
delusional  and  hallucinatory  the  case  is  usually  one  for  commit- 
ment, even  if  the  amount  of  depression  be  not  great.     In  the 


428  MENTAL    DISEASES 

lucid  and  mild  forms  of  melancholia  an  attempt  should  always 
be  made  to  treat  the  patient  outside  of  the  hospital,  and  for 
the  special  reason  that  such  eases  cannot  legally  be  committed. 
No  jury  will  hold  a  perfectly  lucid  patient;  though  the  pres- 
ervation of  lucidity,  as  we  have  learned,  is  by  no  means  an 
index  of  the  degree  or  of  the  intensity  of  the  melancholia. 

Cases  of  melanchoUa  are  especially  adapted  to  rest  methods. 
Quite  commonly  rest  in  bed,  full  feeding,  and  gentle  bed- 
bathing  can  be  instituted  without  much  difficulty.  However, 
this  is  not  usually  the  case  with  massage  or  other  mechanical 
procedure.  The  patients  are  apt  to  be  disturbed  and  made 
nervous  by  the  handling  and  manipulation,  but  occasionally 
a  tactful  and  gentle  nurse  succeeds  in  getting  the  patient 
accustomed  to  it. 

There  is  one  element  in  the  treatment  of  melancholia  that 
must  make  every  conscientious  physician  feel  uneasy  about 
his  patient — no  matter  how  carefully  he  has  surrounded  him 
by  attendants  or  members  of  his  family — and  that  is  the  tend- 
ency to  suicide,  a  tendency  which  is  more  or  less  present  in 
every  case.  Even  in  the  milder  forms  of  lucid  melancholia, 
as  we  have  seen,  the  tendency  unquestionably  exists,  and  this 
is  the  explanation  of  the  majority  of  suicides  of  which  we  read 
in  the  daily  papers.  Self-destruction  is  best  guarded  against 
in  the  asylum,  though  it  cannot  be  absolutely  guarded  against 
even  there.  Outside  of  the  asylum  walls,  where  our  lucid  cases 
of  melancholia  must  necessarily  be  treated,  the  greatest  pro- 
tection must  be  thrown  about  the  patient.  Two  nurses  must 
always  be  insisted  upon,  but  it  is  important  to  see  that  the  mis- 
take is  not  made  of  dividing  the  nurses  into  night  and  day 
nurse,  for  under  such  an  arrangement  neither  continuous  nor 
adequate  supervision  can  be  maintained.  It  is  imperative 
that  the  following  routine  be  instituted:   Nurse  A  begins  the 


TKEATMENT  429 

day  by  first  having  her  otvti  breakfast;  she  then  takes  the 
breakfast  tray  to  the  patient's  room,  and  nurse  B,  who  has  been 
with  the  patient  during  the  night,  goes  off  duty.  Nurse  A 
feeds  the  patient,  and  later  gives  the  bed-bath  and  carries  out 
such  other  treatment  as  may  have  been  instituted.  At  noon 
nurse  B  has  her  dinner,  and  then  takes  the  dinner  tray  to  the 
patient's  room;  nurse  A  now  goes  off  duty.  At  six  or  six 
thirty  nurse  A  has  her  supper,  then  takes  the  supper  tray  to 
the  patient  and  goes  on  duty  for  the  night.  The  next  morning 
she  is  reheved  by  mu-se  B.  In  this  way  the  patient  is  com- 
pletely "covered"  for  every  minute  of  the  twenty-four  hours. 
The  ordinary  division  of  the  nurses  into  day  nurse  and  night 
nurse  of  necessity  permits  of  a  hiatus  at  meal  times  as  well  as 
upon  other  occasions.  Finally,  the  plan  above  outHned  is 
much  better  for  the  nurses;  each  secures  a  good  sleep  every 
other  night  and  has  abundant  time  to  sleep  the  next  morning 
after  a  night  of  duty.  In  long-continued  cases  the  strain  is 
thus  much  better  borne. 

As  pointed  out  in  the  consideration  of  melancholia,  the  pa- 
tient usually  suffers  from  a  loss  of  appetite  which  is  sometimes 
very  pronounced  and  not  infrequently  leads  to  a  refusal  of  food. 
Sometimes- it  is  possible  to  persuade  the  patient  to  eat;  at 
other  times  he  vnW  swallow  the  food  automatically  if  it  be 
placed  in  his  mouth.  Not  infrequently  persuasion  and  the 
cup  and  spoon  are  all  that  is  necessary.  However,  now  and 
then  we  are  obhged  to  resort  to  forcible  feeding.  This  may  be 
accomplished  by  a  tube  introduced  into  the  stomach  by  the 
mouth,  or,  better,  by  a  tube  introduced  through  the  nose. 
Feeding  by  the  stomach-tube  may  encounter  active  resistance 
by  the  patient,  who  may  firmly  cHnch  his  teeth;  if  the  latter 
are  forcibly  separated  there  is  danger  that  he  may  bite  the 
tube  or   the   fingers  of   the  physician.     A  far  readier   and 


430  MENTAL    DISEASES 

much  more  satisfactory  route  is  offered  by  way  of  the  nose. 
At  the  first  feeding,  the  physician  should  have  the  assistance 
of  one  or  perhaps  two  nurses.  The  patient  may  be  seated  in  a 
chair  or  lie  upon  his  bed.  The  nurses  should  prevent  any  unto- 
ward movement  of  the  head  or  any  attempt  on  the  part  of  the 
patient  to  seize  the  tube.  The  nostrils  should  first  be  cleaned 
with  a  little  absorbent  cotton,  and  then  the  nasal  tube,  slightly 
warmed  and  oiled,  should  be  gently  introduced  in  a  direction 
parallel  to  the  floor  of  the  nose.  If  it  be  found  that  resistance 
is  encountered,  due  possibly  to  a  markedly  deflected  septum 
or  other  cause,  the  tube  should  be  withdrawn  and  introduced 
into  the  other  side.  It  should  be  gently  pushed  backward, 
and  will  be  found  to  readily  glide  along  the  posterior  wall  of  the 
pharynx  into  the  esophagus  and  thence  into  the  stomach. 
While  passing  the  tube,  it  is  wise  to  gently  depress  the  chin,  as 
by  this  expedient  the  tube  is  much  less  likely  to  enter  the 
larjmx.  If  the  patient  be  permitted  to  throw  the  head  back- 
ward, the  tube  may  pass  around  the  soft  palate  and  enter  the 
mouth,  where  it  may  curl  upon  itself  or  be  protruded  between 
the  lips.  As  a  rule,  little  or  no  difficulty  is  encountered  in 
properly  introducing  the  tube,  and  the  fact  that  it  is  really  in 
the  stomach  may  be  verified  by  gently  percussing  the  stomach 
while  the  operator  holds  the  free  or  funnel-shaped  end  of  the 
tube  near  his  ear.  The  position  of  the  tube  having  been  de- 
termined, the  food,  which  is  of  course  liquid  in  form,  is  then 
gently  poured  into  the  funnel.  When  the  requisite  amount 
has  been  introduced  the  tube  is  withdrawn.  It  is  important 
while  this  is  being  done  to  compress  the  tube  so  that  no  liquid 
may  escape  from  it  as  its  opening  passes  the  larynx.  In  melan- 
cholia, as  well  as  in  stuporous  states,  the  larynx  is  sometimes 
much  obtunded,  so  that  fluid  or  even  the  tube  itself  may  enter 
it  without  exciting  a  paroxysm  of  coughing  or  immediate  evi- 


TEEATMENT  431 

dences  of  strangulation.  In  but  a  single  case,  a  patient  whom 
the  writer  saw  in  consultation,  did  a  serious  accident  occur; 
milk  had  escaped  into  the  larynx  in  apparently  considerable 
amount;  the  patient  subsequently  died  of  gangrene  of  the 
lungs.  As  a  rule,  however,  the  procedure  is  attended  by  no 
danger,  and  is  performed  with  ease  and  certainty;  and  its 
repetition  is  accompanied  by  a  lessened  and  finally  no  resistance 
on  the  part  of  the  patient. 

The  question  arises,  How  long  is  it  proper  to  wait  before  in- 
stituting forcible  feeding?  If  the  patient  has  for  a  long  time 
been  taking  a  grossly  insufficient  amoimt  of  food,  if  he  has  lost 
weight  decidedly,  it  is  not  wise  to  wait  until  he  refuses  food 
absolutely,  but  to  resort  to  forcible  feeding  before  emaciation 
becomes  serious  or  pronounced.  If  the  patient  has  been  taking 
some,  though  an  insuflacient  amount  of  food,  one  can  wait  with 
safety  two  or  three  days.  If  he  is  well  nourished  and  is  still 
drinking  water,  it  is  safe  to  wait  a  week  or  even  longer.  A 
patient,  under  such  circumstances,  should  of  course  be  under 
close  observation.  It  is  perfectly  possible  for  a  patient  in  a 
state  of  good  nutrition  to  go  without  food  for  a  very  long  time, 
but  it  is  unnecessary  to  run  any  risk,  and  it  is  good  practice,  on 
the  average,  to  feed  after  waiting  three  days. 

The  amount  of  the  feeding  should  be  small  at  first,  say  a 
pint  or  less;  later  this  may  be  increased  to  a  pint  and  a  half, 
to  a  quart,  or  even  more.  The  feeding  should  take  place  twice 
daily.  According  to  judgment,  it  should  contain  milk  and  raw 
eggs.  At  times  a  broth  or  soup  may  be  substituted.  From 
time  to  time,  also,  orange  juice  should  be  given.  It  need 
hardly  be  added  that,  if  necessary,  medicines  may  be  admin- 
istered with  the  feeding.  The  patient's  nutrition,  as  a  rule, 
improves  rapidly,  and  the  method  may  be  kept  up  for  a  long 
time — for  weeks,  for  months,  and,  in  given  cases,  for  years. 


432 


MENTAL    DISEASES 


Sometimes  before  instituting  artificial  feeding  it  is  a  good 
plan  to  wash  out  the  stomach.  Occasionally  vomiting  follows 
the  feeding,  and  in  such  case  it  is  also  wise  to  wash  out  the 
stomach  and  to  wait  a  suitable  interval;  in  the  next  feeding 
the  amount  of  food  should  be  small  and  relatively  simple;  e.  g., 
a  little  peptonized  milk  and  lime-water,  or  perhaps  albumin- 
water. 

A  very  unsatisfactory  procedure  is  that  of  nutritive  enemata. 
These  may  consist  of  peptonized  milk,  peptonized  minced  beef, 
eggs,  etc.  The  bowel  should  first  be  washed  out  and  then 
quieted  by  an  opium  suppository;  a  half -hour  later  the  enema 
may  be  given. 

Occasionally,  in  cases  in  which  both  the  stomach  and  the 
bowel  cease  to  be  retentive,  a  hj^jodermoclysis  of  common  salt 
solution  may  be  resorted  to  wnth  advantage.  Especially  may 
a  crisis  occasionally  be  bridged  over  "by  this  means  when 
weakness  and  emaciation  have  become  marked.  The  fluid  is, 
as  a  rule,  rapidly  absorbed,  the  vessels  become  filled,  and  the 
heart's  action  stronger.  The  procedure  may  of  course  be 
repeated ;  say  twice  daily.  Enteroclysis  may  also  be  employed 
and  often  with  advantage,  though  it  is  naturally  less  efficacious 
than  hjrpodermoclysis. 

It  is  unusual  for  cases  of  melancholia  of  such  a  character 
as  to  permit  of  extramural  care  to  present  the  serious  difficul- 
ties met  with  more  commonly  in  the  graver  asylum  cases. 
However,  they  every  now  and  then  present  themselves,  and 
the  physician  should  be  prepared  to  meet  them.  Commonly 
simple  rest  methods  and  watchful  care  suffice.  Quite  fre- 
quently "partial"  rest  methods  are  entirely  adequate.  In  such 
case  the  patient  rises  late,  lies  do^Ti  in  the  middle  of  the  day,  and 
retires  early  at  night.  He  has  a  daily  sponge  or  brief  immersion 
bath,  massage,  gentle  exercise,  and  full  feeding. 


TREATMENT  433 

The  treatment  of  cases  of  dementia  prsecox  is  likewise  to  be 
based  upon  general  principles.  In  a  large  nmnber  of  cases,  it 
is  a  wise  plan  to  submit  the  patient  to  a  radical  course  of  rest 
treatment  and  to  make  every  possible  effort  to  force  up  the 
nutrition  to  the  highest  possible  level.  The  fact  that  so  many 
cases  die  of  tuberculosis,  especially  of  abdominal  tuberculosis, 
is  a  sufficiently  strong  indication  of  the  wisdom  of  such  a  course. 
As  a  matter  of  fact,  the  body  weight  is  sometimes  increased 
surprisingly  under  these  circumstances,  as  much,  for  example, 
as  twenty  pounds  in  a  month.  Later,  when  the  evidences  of 
gross  impairment  of  nutrition  have  been  in  a  measure  success- 
fully combated,  recourse  may  be  had  to  efforts  at  re-education 
and  retraining;  an  appropriate  occupation  or  various  other 
psychotherapeutic  procedures  may  be  resorted  to.  To  this 
subject  we  will  presently  recur. 

Cases  of  hallucinatory  paranoia  of  average  course  and 
severity,  as  a  matter  of  course,  require  asylum  commitment. 
However,  now  and  then  we  meet  with  mild  and  comparatively 
harmless  cases,  and  the  question  arises  as  to  what  had  best 
be  done.  Usually  the  friends  of  the  patient  stoutly  resist 
conunitment;  at  times,  too,  the  patient's  lucidity  is  such  that 
it  is  doubtful  whether  he  can  be  held  by  the  asylmn  authorities. 
Unfortunately,  here  the  ordinary  physiologic  methods  appli- 
cable to  other  cases  of  mental  disease  are  of  Uttle  use.  The 
best  plan  is  to  secure  some  simple  and  congenial  emplojrment  for 
the  patient.  If  he  is  occupied  and  kept  busy,  he  will  eat  better, 
sleep  better,  and  pay  less  attention  to  his  delusive  ideas.  The 
friends,  however,  should  always  be  warned  that  paranoia,  no 
matter  how  mild,  rarely  remains  stationary,  that  it  is  usually 
a  progressive  affection,  and  that  the  time  may  come  when  the 
patient  will  be  dangerous  and  violent.  The  patients  that  give 
rise  to  the  greatest  diflBiculty  are  cases  of  paranoia  simplex — 

28 


434  MENTAL    DISEASES 

the  non-hallucinatory  form.  Here,  as  we  have  learned,  the  per- 
secutory delusions  may  be  clearly  defined  and  unmistakable, 
and  may  be  a  source  of  serious  annoyance  and  even  danger  to 
others;  and  yet,  if  committed,  the  patient  may  suppress  his 
delusions,  may  employ  counsel,  and  give  friends,  relatives,  and 
physicians  endless  trouble.     (See  p.  165.) 

In  the  neurasthenic-neuropathic  insanities,  the  psychas- 
thenias,  we  have  a  group  of  patients  all  of  whom  must  be 
treated  outside  of  the  asylums;  it  is  very  rarely,  if  ever,  that  a 
commitment  is  justified.  As  has  been  shown,  the  patients 
suffer  from  an  inherent  neuropathy  compUcated  by  a  nervous 
exhaustion  more  or  less  profound.  It  seems  unnecessary  to 
point  out  that  here,  more  than  in  any  other  field,  are  rest 
methods  indicated.  The  latter  should,  whenever  the  patient's 
circumstances  permit  it,  be  instituted  in  the  most  radical  man- 
ner. The  patient  should  be  placed  in  bed;  full  feeding,  gentle 
bathing,  and  massage  should  be  carried  out  elaborately  and 
systematically,  but,  above  all,  the  patient  should  be  submitted 
to  an  absolute  isolation.  The  nurse  should  sleep  on  a  cot  in 
the  patient's  room,  and  no  one  should  have  access  to  the  room 
save  the  nurse  and  the  physician.  The  nurse,  it  is  imnecessary 
to  say,  should  be  of  the  same  sex  as  the  patient.  It  is  impera- 
tive that  a  male  patient  should  have  a  male  nurse. 

It  is  usually  necessarj^  to  give  close  attention  to  the  carrying 
out  of  the  details  lest  the  purpose  of  the  treatment  be  defeated 
by  some  apparently  trifling  neglect.  The  rest  should  be  made 
as  nearly  absolute  as  possible.  The  patient  is  instructed  to  lie 
quietly,  not  to  sit  up,  except  for  the  special  purpose  of  taking 
food,  nor  is  the  patient  to  leave  the  bed  except  for  the  purpose 
of  emptjdng  the  bowels  or  the  bladder.  The  patient  should 
not  only  have  physical  rest,  but,  above  all,  mental  rest,  and  all 


TREATMENT  435 

sources  of  mental  and  emotional  excitement  must  be  rigidly 
avoided.  It  is  for  this  reason  that  isolation  must  be  insisted 
upon.  This  necessitates  the  exclusion  of  relatives  and  friends 
as  well  as  the  suspension  of  all  correspondence. 

The  diet  is  that  appHcable  to  exhausted  states  generally. 
It  is  wise  to  begin  with  a  moderate  amount  of  food  only. 
Sometimes  it  is  wise  to  begin  with  milk  alone,  giving  this  in 
exceedingly  moderate  quantities — 4  to  6  ounces  at  meal-times, 
between  meals,  and  just  before  the  hour  for  sleep.  However, 
in  most  patients  some  solid  food  can  be  given  in  the  beginning. 
As  regards  meats,  the  white  meats  should,  as  a  rule,  be  pre- 
ferred. The  succulent  vegetables — spinach,  squash,  stewed 
celery,  and  later  peas,  string-beans,  and  other  vegetables — 
may  be  added  until  a  full  diet  is  reached.  Eggs  may,  of  course, 
also  be  given.  Potatoes  should  for  a  long  time  be  excluded, 
as  should  also  wheat  bread  in  any  quantity.  The  neuras- 
thenic, however,  is  pre-eminently  in  need  of  a  mixed  diet,  one 
capable  of  furnishing  all  that  the  tissues  require — proteins, 
fats,  carbohydrates,  vegetable  acids,  and  salts;  but  this  full 
diet  should  be  approached  gradually.  The  milk  should  be 
increased  slowly  until  8,  10,  12  or  more  ounces  are  taken  six 
times  daily.  Not  infrequently  the  patient  objects  to  the  milk. 
Sometimes  this  objection  is  based  upon  an  actual  idiosyncrasy, 
so  that  milk  is  digested  with  great  difficulty.  In  such  instances 
we  may  make  a  trial  of  various  forms  of  modified  milk.  At 
times  -the  difficulty  is  overcome  by  the  addition  of  some  alka- 
line water,  still  or  effervescing,  such  as  Vichy,  Seltzer,  or 
Apollinaris,  or  artificial  plain  soda-water.  At  times  the  addi- 
tion of  a  httle  table-salt  makes  the  milk  palatable.  Finally, 
the  milk  may  be  predigested,  or,  what  is  often  a  better  plan,  a 
small  quantity  of  some  digestive  powder,  such  as  pancreatin 


436  MENTAL    DISEASES 

and  sodium  bicarbonate,  may  be  added  to  the  cold  milk  just 
before  the  latter  is  taken.  Buttermilk,  if  it  can  be  obtained, 
is  also  of  great  advantage,  especially  if  there  is  marked  consti- 
pation. In  other  cases,  whey  can  be  employed  with  benefit; 
it  does  not,  however,  answer  as  a  substitute  for  milk  for  any 
lengthy  period.  Kumyss  or,  rather,  imitation  kumyss  is  of 
much  more  value  than  whey,  and  is  frequently  well  digested 
when  milk,  even  modified,  fails.  Occasionally  it  is  necessary 
to  abandon  milk  altogether,  and  under  such  circmnstances  we 
may  resort  to  egg  feeding.  Eggs  are  best  given  raw,  and  should 
be  given  in  increasing  number  daily.  The  procedure  is  as 
follows:  A  raw  egg  is  carefully  opened  and  dropped  into  a  cup 
in  such  a  way  that  the  yolk  is  not  broken.  The  patient  is 
then  directed  to  swallow  the  egg  whole  and  with  a  single  effort. 
It  is  best  to  administer  the  egg  without  salt,  lemon-juice,  or 
other  attempt  at  flavoring.  At  first  it  is  wise  to  begin  with 
one  egg  between  meals,  the  number  being  increased  to  two, 
three,  or  four,  and  even  more,  as  circumstances  permit.  Later, 
a  raw  egg  is  given  after  each  meal — sometimes  two — and 
thus  the  number  of  raw  eggs  is  increased,  so  that  in  many 
instances  quite  a  large  number  are  taken.  As  a  rule,  the  hmit 
is  reached  at  eight  or  ten  eggs.  There  are  patients,  however, 
who  take  as  many  as  a  dozen,  eighteen,  or  even  more  eggs  in  a 
day.  Usually  these  large  quantities  are  well  borne.  Ex- 
ceptionally, however,  if  a  patient  has  taken  a  large  number  of 
eggs,  the  skin  acquires  a  yellowish  tinge.  The  coloring  of  the 
skin  sometimes  alarms  the  patient,  as  it  suggests  an  attack  of 
jaundice.  However,  there  is  no  discoloration  of  the  conjunctivse. 
The  tinge,  too,  is  of  a  brighter  yellow  than  that  seen  in  jaundice. 
The  staining  of  the  skin  can  be  made  to  disappear  by  simply  with- 
drawing the  yolk  and  restricting  the  egg  feeding  to  the  whites 


TREATMENT  437 

of  the  eggs  only.  In  a  few  days  the  coloring  becomes  dis- 
tinctly less  pronounced  and  finally  fades  altogether. 

The  quantity  of  food  which  it  is  possible  to  administer  to 
neurasthenic  patients  at  rest  in  bed  is  sometimes  astonishingly 
large,  and  is  attended  by  a  rapid  increase  in  weight.  If  proper 
precautions  are  taken,  no  digestive  disturbances,  gastric  or 
intestinal,  accompany  this  surcharge  of  the  digestive  tract. 
Great  care  should,  of  course,  be  taken  under  massive  feeding  to 
keep  the  bowels  open,  to  see  that  the  skin  is  kept  active  by 
bathing,  and  to  see  that  the  massage  is  given  thoroughly.  No 
undue  distention  of  the  stomach  or  of  the  abdomen  results, 
and,  when  the  amount  is  again  reduced  to  normal,  no  untoward 
consequences  are  observed. 

Finally,  it  is  important  to  add  that  the  massage  had  best 
be  given  by  the  nurse.  The  introduction  of  a  strange  mas- 
seuse into  the  room  very  frequently  disturbs  the  patient.  The 
masseuse,  if  she  be  not  a  very  tactful  person,  may  create 
havoc  by  the  gossip  and  injudicious  communications  which 
she  may  bring  into  the  room. 

If  the  details  of  the  treatment  be  properly  carried  out, 
various  changes  are  noted,  provided,  of  course,  that  the  case 
progresses  favorably.  It  is  noted  that  the  patient  increases 
in  weight,  the  muscles  become  firm,  the  extremities  cease  to  be 
cold,  and  the  patient  begins  to  lose  her  pallor.  The  patient 
gradually  passes  into  a  condition  of  placidity  and  contentment. 
Nervousness  and  restlessness  give  way  to  quiet  and  an  increas- 
ing sense  of  physical  well-being.  As  the  days  and  weeks  pass 
by,  the  physician  and  his  patient  are  becoming  more  and 
more  closely  acquainted.  The  nurse,  too,  has  learned  to  know 
the  little  personal  peculiarities  of  her  patient,  all  of  which  she 
faithfully  communicates  to  the  physician.  The  conversa- 
tions  between    the   latter  and    the  patient  are  at  first  gen- 


438  MENTAL   DISEASES 

eral  in  character,  but,  as  time  passes,  both  the  physician  and 
the  patient  realize  that  a  complete  understanding  has  not 
yet  been  established  between  them.  Especially  is  this  the 
case  in  the  form  of  mental  disorder  we  are  at  present  consider- 
ing. It  is  wise  for  the  physician  not  to  be  in  a  hurry;  fre- 
quently the  patient  will  break  down  the  barrier  herself  and  say, 
"Doctor,  I  must  some  day  have  a  longer  talk  with  you,"  or 
she  may  communicate  her  desire  to  the  nurse,  who  in  turn  in- 
forms the  doctor.  As  a  rule,  the  conversation  proves  to  be  a 
long  one,  the  patient  thoroughly  relieves  her  mind  of  various 
matters,  speaks  to  the  doctor  of  her  personal  affairs,  unloads  her 
worries  and  cares,  and  at  times  speaks  of  some  one  matter, 
perhaps  an  intimate  personal  fact,  that  has  been  worrying  and 
distressing  her.  In  the  experience  of  the  writer  it  is  infrequent 
for  this  fact  to  deal  A\dth  the  sexual  life  of  the  patient,  though 
this  is  every  now  and  then  the  case;  and  his  experience  has 
been  the  same  with  both  male  and  female  patients.  Further, 
the  memories  of  sexual  experiences  are  not  so  hidden  and 
obscure  as  to  necessitate  the  elaborate  and  tedious  methods 
followed  by  Freud  and  his  followers.  As  a  rule,  too,  a 
physician  experiences  in  rest  treatment  no  difficulty,  by 
simple  and  direct  methods,  in  determining  the  factors  of 
real  importance,  sexual  or  other.  The  opportunities  offered 
by  the  daily  visits  of  the  physician,  the  increasing  confidence 
of  the  patient,  and  her  tendency  to  seek  the  relief  which  a 
free  discussion  of  her  case  affords,  lead,  as  a  rule,  to  the 
gradual  disappearance  of  the  special  fears,  the  phobias,  from 
which  she  suffers.  During  all  of  this  time,  be  it  remembered, 
the  bodily  condition  is  undergoing  marked  improvement,  large 
amounts  of  food  are  being  digested  and  assimilated,  the  heart's 
action  is  no  longer  rapid  or  disturbed,  tachycardia  no  longer 
occurs,  the  hands  and  feet  and  the  general  body  surface  are 


TREATMENT  439 

warm,  sleep  is  normal  in  amount  and  refreshing,  and  the  atti- 
tude of  mind  ceases  to  be  introspective.  Soon  a  sense  of  well- 
being  becomes  estabhshed,  which  httle  by  httle  becomes  more 
and  more  pronounced,  until  morbid  ideas  of  all  kinds  are 
crowded  from  the  field  of  consciousness.  Buoyancy,  ex- 
pectancy, spontaneity,  self-assertion,  a  desire,  and  finally  a 
demand,  for  action  mark  the  transformation.  During  all  of 
this  period  the  patient's  mind  offers  a  fertile  field  for  psycho- 
therapeutics. Suggestion  by  the  physician  as  to  the  disap- 
pearance of  the  phobia  now  grafts  itseff  upon  the  willing 
mind  of  the  patient  with  tenacious  force;  chronic  indecision 
and  aboulia,  imder  the  powerful  stimulus  of  the  physical 
invigoration  and  the  added  stimulus  of  the  physician's  will, 
lessen  and  disappear.  Time  is  required,  it  is  true,  but  this 
extends  as  a  rule  over  a  number  of  months  only;  three  or 
four,  not,  as  in  psychanalysis,  over  two  and  three  years. 

The  degree  of  success  achieved  in  a  given  case  depends 
largely  upon  two  factors:  first,  the  degree  of  neuropathy 
present,  and,  second,  the  length  of  time  during  which  the 
special  symptoms  present  have  persisted.  Chronic  indecision 
and  aboulia,  as  a  rule,  disappear  comparatively  readily;  in 
connection  with  these  symptoms  we  must  bear  in  mind  the 
not  infrequent  presence  of  disturbances  of  the  internal  secre- 
tions, more  especially  of  thyroid  inadequacy,  and  the  conse- 
quent benefit  to  be  derived  from  the  administration  of  thyroid 
extract.  The  phobias  also  eventually  disappear,  though  in 
their  case  it  is  frequently  necessary  to  maintain  suggestion  and 
retraining  for  some  time  after  the  bed-period  of  treatment  has 
been  concluded.  The  symptoms  due  to  defective  inhibition, 
the  peculiar  gestures,  "defensive"  movements,  coprolalia,  tics, 
and  like  phenomena  are  much  less  promising.  However,  if 
the    affection    has   not   been   present  long,  if    the  patient  is 


440  MENTAL    DISEASES 

still  young,  great  success  may  attend  our  efiforts.  Even 
in  long-standing  cases  much  is  now  and  then  accomplished 
by  rest,  especially  if  this  be  followed  by  persistent  exer- 
cise. The  character  of  the  exercise  is  very  important; 
the  latter  should  consist  of  slowly  carried  out  movements  of 
precision,  which  should  gradually  be  made  more  comphcated 
and  difficult.  Such  movements  require  mental  concentration 
and  a  sustained  action  of  the  wall.  Accompanied  by  encour- 
agement and  suggestion,  this  method  not  infrequently  leads 
to  a  gratifying  result.  However,  severe  and  long  established 
tics,  especially  tj^pical  tic  convulsif,  prove  to  be  resistant  and 
inveterate,  probably  because  of  the  more  pronounced  character 
of  the  neuropathy. 

Compared  with  psychanalysis,  the  above  procedure — the 
rest  treatment  of  Weir  Mitchell  combined  with  psychotherapy 
— yields  results  incomparably  greater,  more  durable,  and  in  a 
much  shorter  period  of  time.  No  one  questions  the  fact  that 
the  full  recital  by  the  patient  to  her  physician  of  her  symptoms 
and  of  all  of  the  associated  details  is  a  source  of  relief. 
Every  neurologist  of  experience  will,  I  think,  admit  its  truth. 
The  relief  which  persons  experience  from  a  full  account  of 
their  sjnnptoms  and  the  inevitable  concomitant  emotional  dis- 
charge, is  seen,  in  a  more  marked  degree  of  course,  and  yet 
typically,  in  the  making  of  confessions;  at  times  the  demand 
for  relief  under  these  circumstances  is,  as  is  well  known,  so 
great  and  so  insistent  that  the  sufferer  voluntarily  makes 
statements  which  he  knows  may  lead  to  disgrace,  imprison- 
ment, and  at  times  even  to  death.  ■ 

Rest  and  the  psychotherapeutic  procedures  above  detailed 
are  applicable  of  course  also  to  hysteria,  in  which  the  results 
achieved  by  these  means  are  alike  successful  and  often  brilliant 


TREATMENT  441 

and  remarkable.  Freud  speaks  of  achieving  results  in  from 
six  months  to  three  years;  by  rest  methods  the  time  is  fre- 
quently counted  by  weeks.  Finally,  it  should  be  added  that 
full  rest  methods  are  not  always  necessary,  but  that  "partial 
rest"  often  suffices.  Space  will  not  permit  of  a  consideration 
of  partial  rest  in  detail;  it  implies  an  increased  amount  of  rest 
secured  by  retiring  early,  rising  late  and  lying  down  during  a 
part  of  the  day,  together  with  full  feeding,  gentle  exercise, 
bathing,  and  perhaps  massage.  Suitable  occupation  in  the 
intervals  must  not  be  forgotten. 

That  the  psychotherapeutic  methods  above  outlined  should 
be  applied,  in  so  far  as  they  are  indicated,  in  every  case  sub- 
mitted to  rest  treatment,  it  is  not  necessary  to  add.  They  are 
applicable  in  melanchoha,  in  dementia  prsecox,  as  well  as  in 
other  mental  affections;  that  their  usefulness  in  dementia 
prsecox  is  much  more  limited  is  equally  evident. 

The  general  principles  of  the  rest  treatment  are  also  espe- 
cially applicable  to  the  intoxications.  (See  p.  212.)  If  the  pa- 
tient be  placed  in  bed  and  have  adequate  supervision  by  nurses, 
the  alcohol,  morphin  or  cocain  can  be  withdrawn  at  the  will 
of  the  physician.  An  ideal  plan  of  treating  a  drug-habit  is  to 
institute  absolute  isolation  with  two  trained  nurses,  according 
to  the  method  already  described.  (See  p.  428.)  By  this  means 
access  to  drugs  and  stimulants  can  be  entirely  prevented.  At 
the  same  time,  full  rest  treatment,  with  liberal  feeding,  bed- 
bathing,  and  massage  can  be  thoroughly  carried  out. 

Usually  alcohol  can  be  withdrawn  at  once;  though,  if  the 
patient  show  the  marked  effects  of  a  recent  excess,  it  may  be 
wiser,  because  of  the  possible  danger  of  an  attack  of  delirium, 
to  make  the  withdrawal  gradual.  However,  the  moral  effect 
of  a  too  prolonged  withdrawal  is  bad,  and  a  withdrawal  as 
rapid  as  is  consistent  with  safety  should  be  instituted. 


442  MENTAL    DISEASES 

In  the  case  of  morphin,  it  is  much  wiser  to  make  the  with- 
drawal gradual.  It  is  my  practice  not  to  begin  withdrawal  of 
the  drug  until  rest-treatment  is  fully  under  way.  One  must 
remember  that  the  morphin  habitue  labors  under  an  excessive 
fear  lest  the  drug  be  withdrawal  too  soon.  Besides,  sudden 
withdrawal  ahvays  implies  a  period  of  frightful  physical  and 
mental  suffering.  Further,  the  patient  is,  as  a  rule,  intensely 
distrustful.  I  know  of  no  class  of  patients  with  whom  it  is 
more  difficult  to  establish  friendly  relations  or  in  whom  it  is 
more  difficult  to  inspire  confidence.  However,  if  the  patient 
learns,  after  his  first  few  days  of  rest  and  isolation,  that  he  is 
still  recei\ing  his  hypodermic  injections,  or  that  he  is  still 
being  allow^ed  his  usual  quantity  of  laudanum  or  opium,  con- 
fidence sooner  or  later  asserts  itself,  especially  as  the  physical 
comfort  resulting  from  the  bathing,  massage,  and  proper  diet 
soon  becomes  pronounced.  My  practice  is  almost  invariably 
that  of  very  gradual  withdrawal.  The  withdrawal  should  be 
so  slow  at  first  that  the  diminution  of  the  dose  is  practically 
imperceptible;  later  on  the  reduction  may  be  more  rapid.  If 
the  patient  has  been  in  the  habit  of  receiving  hypodermic  in- 
jections, it  is  my  plan  not  only  to  reduce  the  dose  gradually 
in  the  manner  indicated,  but  also  to  begin  adding  to  the  in- 
jection small  doses  of  strychnin  sulphate,  say  Jj  of  a  grain, 
and  if  the  skin  be  very  moist,  small  doses  of  atropin  sulphate, 
say  2-5-0  of  a  grain.  As  the  dose  of  the  morphin  is  diminished, 
hyoscin  or  scopolamin  should  be  added  to  the  hypodermic  in- 
jection, first  in  small  and  then  in  larger  doses.  As  a  rule,  the 
atropin  may  be  discontinued  if  the  scopolamin  be  given. 
There  can  be  no  question  that  hyoscin  and,  more  especially, 
scopolamin  greatly  relieve  the  suffering  of  the  patient  and  keep 
him  much  quieter  than  he  would  otherwise  be.  There  is,  of 
course,  no  danger  of  the  formation  of  a  hyoscin  or  scopolamin 


TREATMENT  443 

habit;  and,  besides,  the  physician  is  in  complete  control  of  the 
situation.  The  physician  should  be  especially  cautioned  not 
to  make  use  of  cocain  during  the  withdrawal,  or,  in  fact,  at 
any  time,  inasmuch  as  the  patient  may  sooner  or  later  acquire 
the  cocain  habit,  with  disastrous  results.  Further,  a  large 
number  of  patients  that  come  under  our  care  for  the  morphin 
habit  have  already  acquired  the  cocain  habit.  The  same  re- 
marks apply  also  to  alcohol. 

My  reason  for  withdrawing  the  morphin  in  the  gradual  manner 
above  described  is  not  only  to  diminish  the  sufferings  of  the 
patient,  but  also  to  prevent  the  onset  of  serious  symptoms. 
Every  now  and  then,  if  the  drug  be  abruptly  withdrawn,  signs 
of  collapse,  diarrhea,  sweating,  cardiac  weakness,  and  dyspnea, 
with  excessive  prostration,  may  set  in.  In  other  cases,  again, 
mental  symptoms  resembling  those  of  confusional  insanity 
make  their  appearance,  the  patient  becoming  hallucinatory, 
delusional,  and  finally  delirious.     (See  page  231.) 

As  regards  cocain,  it  is,  as  a  rule,  practicable  to  withdraw  the 
drug  at  once.  It  is  true  that  insomnia,  palpitation,  dyspnea,  and 
collapse  are  liable  to  occur,  but  they  can  be  much  more  readily 
controlled.  As  a  rule,  the  writer  practices  immediate  with- 
drawal; the  experience  of  Norris  is  entirely  the  author's  ex- 
perience. The  bromids  are  very  efficacious  in  combating  the 
symptoms.  Many  cocainists  sleep  spontaneously  after  the 
mere  withdrawal  of  the  drug,  but  it  is  usually  a  good  plan  to  give 
moderate  doses  of  trional  or  sulphonal  at  night.  In  the  early 
morning  coffee  may  be  given  to  lessen  the  depression.  In 
cases  in  which  morphinism  and  cocainism  co-exist,  the  cocain 
may  usually  be  withdrawn  at  once.  The  morphin  should, 
however,  be  withdrawn  in  the  gradual  manner  already  described. 
In  cases  in  which  the  alcohol  habit  is  also  present,  it  is  expedient 
to  withdraw  the  cocain  at  once,  the  alcohol  rapidly,  and  the 


444  MENTAL    DISEASES 

morphin  slowly.  The  morphin  distinctly  overshadows  the  other 
drugs,  and,  as  a  rule,  it  had  best  be  continued  in  full  doses  for 
a  number  of  days.  Later  it  may  itself  be  gradually  diminished. 
In  other  words,  the  treatment  of  the  "triple  habit"  resolves 
itself,  sooner  or  later,  into  that  of  simple  morphinism. 

That  inebriates  should  be  under  supervision  for  a  very  long 
period  is  of  course  imperative,  and  that  everything  should  be 
done  by  the  way  of  occupation,  moral  influence,  and  psycho- 
therapy need  hardly  be  emphasized. 

Elaborate  rest  methods  are,  of  course,  out  of  the  question 
with  the  larger  mmiber  because  of  the  expense  entailed.  Un- 
fortunately the  law  does  not  as  yet  make  possible  an  adequate 
restraint  of  inebriates,  so  that,  even  when  the  patient  has  the 
necessary  means,  nothing  can  be  accomplished  by  the  most 
elaborate  care  unless  he  is  entirely  willing.  Even  when  the 
patient  is  willing  to  commit  himself  to  an  institution,  the  com- 
mitment only  holds  for  a  very  limited  period;  e.  g.,  thirty  days, 
a  time  which  is  of  course  utterly  inadequate.  Usually  it  is  only 
when  the  patient  has  passed  fully  beyond  the  legal  boundary  of 
sanitj'^  that  he  can  be  properly  committed  and  restrained.  It 
is  unfortunate,  to  say  the  least,  that  we  must  frequently  wait 
until  crass  insanity  supervenes  before  effective  treatment  can 
be  instituted. 

Rest  methods  should  also,  other  things  equal,  be  carried  out 
in  connection  with  the  treatment  of  paresis.  Their  thorough 
appHcation  plays  a  large  part  in  the  results  achieved  by  salvarsan 
and  other  therapy.    (See  p.  309.) 

Surgical  procedures  have,  as  may  readily  be  inferred,  only  a 
small  role  in  mental  diseases.  Aside  from  the  rare  cases  in 
which  there  is  gross  disease,  such  as  tumor,  focal  epilepsy, 
abscess  and  the  like,  surgery  can  play  no  role.     In  microcephaly 


TREATMENT  445 

the  operation  of  craniectomy  has  deservedly  been  abandoned. 
This  is  also  the  case  with  operations  upon  the  pelvic  organs; 
experience  has  shown  that  mental  disease  is  uninfluenced  by 
them.  Pelvic  operations  in  the  insane  should  be  based,  as 
in  other  cases,  upon  surgical  indications  only.  This  is  equally 
true  of  operations  involving  other  portions  of  the  organism. 
Again,  experience  militates  against  interfering  with  a  preg- 
nancy when  during  its  course  mental  s>Tnptoms  have  made 
their  appearance.  As  we  have  seen,  the  tendency  is  to  the 
persistence  of  the  mental  symptoms  after  pregnancy  has  ter- 
minated normally,  and  this  course  is  not  changed  when  the' 
pregnancy  is  terminated  by  miscarriage  either  induced  or 
spontaneous. 

Occasionally  there  is  a  remarkable  cessation  of  progress,  and 
at  times  a  recovery,  in  mental  cases  in  the  course  of  which  there 
is  an  attack  of  some  acute  febrile  infection,  such  as  typhoid 
fever  or  erysipelas.  Less  frequently  similar  results  are  ob- 
served after  an  abscess  with  febrile  reaction.  It  would  seem 
as  though  we  had  here  to  do  with  the  formation  of  antibodies; 
such  an  interpretation  is  in  keeping  with  the  view  of  the  toxic 
nature  of  the  psychoses.  Sometimes  remissions  and  arrest 
of  progress  have  been  noted  after  severe  trauma  or  severe 
surgical  shock. 

INTRAMURAL  TREATMENT 

The  general  principles  of  treatment  appHcable  to  extra- 
mural cases  are  of  course  the  same  for  intramural  cases. 
However,  the  problems  presented  are  in  the  main  very  differ- 
ent. We  must  remember  that  cases  suitable  for  extramural 
care  are,  on  the  whole,  the  most  favorable,  both  as  regards  the 
possibihties  of  therapeutics  and  the  hkehhood  of  recovery. 
They  are,  at  the  same  time,  the  least  disturbed  and  the  most 


446  MENTAL   DISEASES 

amenable  to  treatment;  the  treatment  also  is  more  individual. 
If,  therefore,  it  be  maintained  that  the  results  of  extramural 
treatment  are  more  favorable  than  those  of  the  institutional, 
these  important  facts  must  be  borne  in  mind.  Finally,  the 
physician,  finding  after  a  trial  that  the  proper  care  of  a  patient 
is  not  practicable  outside,  always  has  the  resource  of  com- 
mitment. 

In  the  institutions  are  naturally  found  the  great  mass  of 
disturbed  cases,  the  chronic  demented  and  hopeless  forms,  and 
also  that  great  number  whose  means  do  not  permit  of  extra- 
mm"al  care,  a  care  which  is  always  expensive.  We  should 
remember  that  even  isolation  in  a  private  room  necessitates 
the  employment  of  a  special  nurse;  indeed,  usually  of  two. 

The  modern  hospital  for  the  insane  approximates  more  or 
less  closely  the  ordinary  hospital.  Of  necessity,  provision  is 
made  for  cases  confined  to  bed  either  by  reason  of  mental  or 
physical  incapacity,  as  in  the  dementias,  stupors,  catatonias, 
and  the  like.  Bed-treatment  as  such — i.  e.,  bed-treatment 
based  upon  rest  principles — is  still  to  a  large  extent  imprac- 
ticable. It  necessitates  a  corps  of  trained  nurses,  and  de- 
mands an  amount  of  individual  attention  which  it  is  as  yet 
impossible  for  most  hospitals  to  give;  at  least,  to  large  numbers 
of  cases.  However,  it  is  being  introduced  to  an  increasing 
extent.     General  hospital  care,  of  course,  is  found  everywhere. 

Among  the  recent  hospital  admissions,  there  are  many  patients 
who  from  privation,  from  the  burden  of  life,  from  the  struggle 
for  existence,  from  the  absence  of  physiological  living  or  from 
worries  and  anxieties  often  too  hard  to  bear,  have  broken  down, 
and  who  in  addition  to  their  mental  symptoms,  present  striking 
and  important  physical  features  as  well.  Other  things  equal, 
an  ideal  plan  of  handling  a  recent  admission  and  especially  if 
the  patient  be  in  a  first  attack,  is  to  place  the  patient  in  bed 


TREATMENT  447 

and,  secondly,  to  examine  him  exhaustively  from  the  standpoint 
of  internal  medicine,  just  as  is  done  in  the  wards  of  a  general 
hospital.  Not  only  should  this  include  a  visceral  examination, 
a  study  of  the  circulatory  apparatus,  and  of  the  digestive  tract, 
of  the  blood  and  secretions,  of  the  possible  infections,  of  the 
disorders  of  nutrition  and  metabohsm,  emaciation,  obesity, 
and  what  not,  but  especially  should  we  seek  for  evidences  of 
disorders  of  the  internal  secretions.  These,  as  is  well  known, 
are  frequently  present.  Such  evidences  are  rarely  pronounced; 
indeed,  they  are  commonly  quite  shght,  but  nevertheless  present. 
Thus,  hypothyroidism  may  express  itself  by  a  very  moderate 
degree  of  infiltration  of  the  skin  and  dryness  of  the  surface; 
only  exceptionally  may  we  note  anything  approaching  a  typical 
myxedema,  and  yet  the  disorder  of  secretion  present,  though 
moderate  in  degree,  may  be  of  profound  chnical  significance. 
The  same  holds  true  of  course  for  hyperthyroidism;  the  symp- 
toms may  not  be — usually  are  not — sufficiently  pronounced 
to  present  an  exophthalmus  or  other  striking  feature,  but,  per- 
haps merely  a  tachycardia,  ready  sweating  or  ready  exhaustion. 
Especially  important  is  it  to  note  the  history  of  the  patient  in 
regard  to  the  development  of  the  sex  glands.  For  instance,  a 
delayed  or  imperfect  puberty,  the  history  of  a  late  oncoming  and 
irregular  menstruation  never  properly  established,  is  of  great 
significance.  The  researches  of  Fauser  and  others  point,  as  we 
have  seen  (p.  131),  to  the  sex  glands  as  playing  an  important  role 
in  endogenous  mental  deterioration,  especially  in  dementia 
prsecox.  Here  studies  by  Fauser  and  others  have  led  to  the  con- 
clusion that  an  abnormal  hormone  is  thrown  into  the  blood 
by  the  sex  glands,  that  the  presence  of  this  hormone  evokes 
the  production  of  defensive  ferments  which  in  turn  are  injurious 
to  the  cortex  and  bring  about  the  destruction,  the  lysis,  of  the 
latter.    Again,  abnormahties  in  the  sexual  development  which 


448  MENTAL    DISEASES 

may,  on  the  one  hand,  be  retarded  and  incomplete  or  on  the  other 
precocious  or  excessive,  may  point  in  given  instances  to  the 
pituitary  gland  and  in  other  instances  to  the  pineal  gland. 
Finally,  mixed  clinical  pictures  are  often  presented,  which  justify 
the  inference  that  a  number  of  the  glands  of  internal  secretion 
are  disturbed ;  perhaps  the  entire  chain  of  glands  is  defective  or 
aberrant  in  development. 

In  addition,  recent  cases  frequently  present  the  marked 
evidences  of  nervous  exhaustion  or  of  some  other  general  im- 
pairment of  nutrition.  All  things  considered,  it  would  seem  wise 
to  place  recent  cases  in  bed  and  to  institute  a  more  or  less  radical 
course  of  rest  and  full  feeding. 

I  am  aware,  of  course,  that  these  measures  are  applicable 
only  to  a  limited  number  of  the  insane,  but  the  latter  are  un- 
questionably to  be  found  among  the  cases  of  recent  origin. 
Naturally,  too,  the  rest  is  especially  appUcable  and  most  readily 
carried  out  in  the  milder  and  less  disturbed  cases  and  are  here 
productive  of  the  most  striking  results.  Again,  many  patients 
are  kept  in  bed  with  difficulty,  while  others  again  take  to  their 
beds  spontaneously,  and  such  factors  must  of  necessity  influence 
the  result.  However,  when  apphcable  the  indications  for  radical 
rest  are  very  clear.  Rest  is  an  expedient  of  great  power.  By 
its  means  the  expenditure  of  energy  is  reduced  to  a  minimum, 
the  consumption  of  tissue  is  greatly  diminished  and  a  lessened 
amount  of  waste  material  is  thrown  into  the  circulation.  The 
strain  upon  the  neuromuscular  apparatus  and  upon  the  heart 
and  blood-vessels  is  to  a  great  extent  removed,  while  the  glands 
of  internal  secretion  also  have  lessened  demands  made  upon 
them.  The  last-mentioned  fact  assumes  a  marked  importance 
when  we  recall  how  frequently  in  the  insane  these  glands  are 
deficient,  inadequate,  or  aberrant. 

When  we  turn  to  the  question  of  full  feeding,  we  find  that 


TREATMENT  449 

this  is  as  imperative  here  as  in  simple  and  uncomplicated  neuras- 
thenic states.  Full  feeding  means  hypernutrition,  and  hypernu- 
trition  not  only  adds  to  the  substance  of  the  body  but  also 
profoundly  influences  metaboUsm.  In  excessive  feeding,  for 
instance,  protein  substances  which  have  been  only  partially 
reduced,  gain  access  not  only  to  the  portal  circulation  but  even 
pass  through  the  liver.  Once  in  the  blood,  the  latter  assumes  the 
function  of  completing  the  digestion.  It  would  appear  that  all 
the  cells  of  the  body  in  addition  to  the  special  function  imposed 
upon  them  by  the  special  organs  or  tissues  of  which  they  are 
component  parts,  also  retain  the  primitive  function  of  digestion, 
and  it  would  appear  that  in  no  tissue  is  this  function  better 
preserved  than  in  the  blood.  Here  the  various  leukocytes, 
the  plasma,  and  even  the  erythrocytes  and  the  blood-plaques 
play  a  role.  Abderhalden  found,  in  accordance  with  this  truth, 
that  ferments  make  their  appearance  in  the  blood  when  the 
intestinal  tract  is  overfilled  with  protein,  peptones,  or  carbo- 
hydrates. In  massive  egg  feeding,  for  instance,  unchanged 
protein  enters  the  blood  and  can  be  demonstrated  by  the  pres- 
ence of  ferments.  In  exhausted  and  enfeebled  states  it  stimu- 
lates thus  the  formation  of  antibodies.  In  the  toxic  insanities, 
those  resulting  from  poisons  introduced  from  without  and  those 
resulting  from  the  infections,  the  role  of  overfeeding  is  thus 
made  clear;  but  this  role  is  equally  clear  in  the  autotoxic  states, 
for  these  are  in  a  sense  self -infected  cases  and  the  problem  in  no- 
wise differs,  for  instance,  from  that  offered  by  tuberculosis. 
Finally,  not  only  is  the  ferment-producing  power  of  the  blood 
stimulated  in  hyperfeeding,  but  the  lipoid  substances  also  are 
largely  increased  in  amount,  and  lipoids,  as  we  know,  play  a 
most  important  role  in  the  formation  of  antibodies. 

The  problem  that  confronts  us  in  insanity  is  not  only  one  of 
exhaustion  but  also  of  intoxication,  and  under  these  circum- 

29 


450  MENTAL    DISEASES 

stances  hypemutrition  assumes,  as  we  have  seen,  a  special  signifi- 
cance and  importance.  The  intoxications  to  which  the  organ- 
ism is  subject  may  be  roughly  divided  into  two  groups.  Some 
poisons  exercise  but  a  short  tenure;  that  is,  the  intoxications 
which  result  from  them  are  of  short  duration.  In  such  instances 
the  organism  successfully  resists  and  disposes  of  the  poisons 
speedily  and  promptly.  Such  poisons  are  successively  submit- 
ted to  the  defensive  action  of  the  gastro-intestinal  juices,  the 
defensive  action  of  the  liver  and  other  glands,  are  variously 
changed  chemically,  and  finally  destroyed  or  eliminated;  but 
these  are  not  the  poisons  nor  the  processes  which  usually 
concern  us  in  insanity.  The  poisons  with  which  we  deal  in 
mental  diseases  are  mainly  those  of  long  tenure,  those  which  are 
not  destroyed  by  the  various  glands  and  other  defensive  struc- 
tures, and  which  consequently  influence  the  metabohsm  of  the 
organism  for  long  periods  of  time,  usually  many  months.  Not 
only  is  this  true  of  the  poisons  present  in  mental  diseases  which 
are  essentially  neuropathic  and  hereditarj'',  such  as  the  manic- 
depressive  group  and  the  group  of  dementia  prsecox  and  para- 
noia, but  also  of  those  in  which  the  poisoning  is  primarily  of 
extraneous  origin.  Thus,  when  prolonged  insanities  ensue  after 
acute  infections,  the  poisons  at  work  have  their  origin  in  a 
secondary  disturbance  of  function  of  the  liver,  of  the  thjToid, 
of  the  kidney,  of  the  adrenals,  and  of  other  glands  and  tissues. 
The  fact  of  such  involvement  is  based  on  indisputable  clinical 
and  pathological  evidence.  Consequently,  a  disorder  of  metab- 
olism ensues  which  constitutes  of  itself  an  auto-intoxication,  an 
auto-intoxication  secondary  to  the  original  infection.  However, 
whatever  the  character  or  the  source  of  the  intoxication,  nature 
is  forced  to  fight  the  battle  by  the  gradual  formation  of  anti- 
bodies, i.  €.,  by  the  continued  effort  at  immunization. 

In  a  patient  who  is  resting  and  who,  in  addition,  is  receiving 


TREATMENT  451 

large  amounts  of  nourishment,  we  must  compensate  for  the 
absence  of  exercise  whenever  practicable  by  massage.  I  shall 
not  dwell  upon  the  applicability  of  this  procedure  in  the  insane. 
Individual  cases  permit  of  the  expedient  in  varying  degrees; 
in  others  it  is  clearly  inapplicable.  In  some,  passive  exercises 
or,  better  still,  exercises  with  resistance  can  be  instituted;  all 
depends  upon  the  character  and  peculiarities  of  each  individual 
case.  There  is  one  important  fact,  however,  in  regard  to  massage 
that  is  not  generally  known,  and  it  is  one  that  emphasizes 
the  great  value  of  massage.  Many  years  ago  in  making  a  blood 
count  of  a  specimen  of  blood  taken  from  a  limb  before  massage 
and  comparing  this  with  the  blood  count  of  a  specimen  taken 
immediately  after  massage,  Dr.  John  K.  Mitchell  noted  a 
largely  increased  percentage  of  red  blood-cells.  This  was,  of 
course,  a  relative  increase  only.  It  is  obvious  that  during  mas- 
sage, doubtless  during  the  process  of  kneading,  the  liquid  por- 
tions of  the  blood  are  forced  into  the  tissues.  The  liquids  of  the 
blood  are  thus  brought  into  actual  contact  with  the  cells  and  it  is 
extremely  probable  that  in  this  way  local  nutrition  is  especially 
stimulated.  Ordinarily  we  thinlv  of  massage  only  as  benefiting 
the  circulation,  as  increasing  the  flow  of  blood  to  the  part  rubbed, 
but  evidently  it  accomplishes  much  more  than  this. 

In  addition  to  rest,  hyperfeeding,  and  massage  there  remains 
another  powerful  expedient,  namely,  that  of  bathing.  It  is  not 
my  intention  to  dwell  upon  the  familiar  fact  that  bathing 
stimulates  elimination.  It  does  really  more  than  this,  however; 
in  its  way  it  also  stimulates  metabolism  and  at  times  is  attended 
even  by  a  slight  increase  in  the  intake  of  oxygen.  It  is  important, 
however,  to  emphasize  the  fact  that  in  patients  undergoing 
rest  treatment  bathing  should  not  be  vigorous;  indeed,  in  the 
average  case  it  is  best  limited  to  gentle  sponge-bathing  in  bed 
between  blankets. 


452  MENTAL    DISEASES 

That  rest  and  hyperfccding,  to  achieve  a  maximum  result, 
should  be  carried  out  for  weeks  and  months  goes,  of  course, 
without  saying.  How  long  they  should  be  employed  depends  of 
course  upon  each  individual  case,  upon  the  progress  made,  upon 
the  gain  in  weight,  and  upon  other  factors.  It  may  be  safely 
said  that  when  the  level  of  the  general  health  of  the  patient  has 
been  distinctly  raised,  or  better,  when  the  latter  has  apparently 
reached  the  highest  level  possible  under  rest  measures,  exercise, 
diversion,  employment  may  gradually  be  instituted. 

The  most  serious  problem  in  asylums  for  the  insane  is  always 
that  presented  by  the  disturbed  cases.  Here  an  expedient 
practised  extensively  in  Germany  for  the  last  fifteen  j^ears, 
especially  by  Kraepelin,  has  proved  to  be  wonderfully  efficacious. 
This  consists  in  the  use  of  the  prolonged  warm  immersion  bath 
(Dauerbad).  The  patient  is  placed  in  a  bath  of  a  temperature 
of  95°  F.  and  allowed  to  remain  in  the  bath  for  one  or  two  hours, 
several  days,  several  weeks,  or,  it  may  be,  for  months.  The 
procedure  is  especially  adapted  to  active  deUria;  e.  g.,  delirium 
tremens,  to  acute  mania,  to  the  excited  periods  of  dementia 
prsecox,  and  to  other  acute  disturbances. 

The  patient  who  has  been  noisy  and  struggling  soon  becomes 
quieted.  The  warm  water  has  a  calmative  and  relaxing  in- 
fluence, the  freedom  of  restraint  offered  by  the  absence  of  cloth- 
ing and  the  fact  that  the  body  half  floats  in  the  water,  lessens 
the  tendency  to  resistance.  Resistance  is  to  a  large  extent 
reflex  and  is  stimulated  by  that  which  it  encounters.  The 
bath  also  greatly  favors  elimination.  There  is  a  rapid  fall  of 
blood-pressure,  due  to  dilatation  of  the  peripheral  vessels; 
probably  there  is  also  a  corresponding  lessening  of  tension 
and  fulness  in  the  cerebral  vessels.  The  pulse-rate,  respiration, 
and  bodily  temperature  reveal  no  changes  of  moment. 

If  the  patient  continues  to  struggle  or  to  be  restless  in  the 


TREATMENT  453 

bath,  Kraepelin  does  not  force  him  to  remain  in  it,  but  renews 
the  attempt  after  an  interval.  Sooner  or  later,  the  patient 
gets  used  to  the  procedure  and  is  placed  in  the  bath  without 
difficulty.  A  dose  of  sulphonal  may  be  given  some  hours 
before  or  a  hypodermic  injection  of  hyoscin  shortly  before. 
The  plan  practised  by  Pfisterer  of  giving  morphin,  gr.  |  or  |, 
together  with  scopolamin,  gr.  2-^0  or  yi^,  hypodermic  ally  be- 
fore the  bath,  seems  to  be  ideal,  and  can  certainly  do  no 
harm,  while  it  greatly  diminishes  the  chances  of  injury  in 
violent  cases.  Luminal  sodium  hypodermically  would  here 
also  seem  to  be  especially  applicable. 

The  patient  may  go  to  sleep  in  the  bath  or  upon  being  re- 
moved to  his  bed.  As  indicated  above,  he  may  be  permitted  to 
remain  in  the  bath,  according  to  circumstances,  for  an  indefi- 
nite period.  The  desire  for  food  is  much  increased,  and,  as 
a  rule,  the  patient  is  fed  very  readily.  The  nourishment  should, 
just  as  in  a  bed  case,  be  given  at  regular  intervals  and  if  neces- 
sary night  and  day.  The  bowel  movements  and  urine  are  dis- 
charged directly  into  the  water  and  carried  off  by  the  discharg- 
ing pipe;  the  advantages  of  this  in  filthy  cases  needs  no  com- 
ment. Bed-sores  are  prevented,  or,  if  they  have  already  oc- 
curred, are  kept  ideally  clean.  Finally,  the  occurrence  of 
menstruation  offers  no  obstacle  to  the  treatment. 

Cases  of  agitated  melancholia  are  not  adapted  to  this  treat- 
ment, according  to  Kraepelin,  and  this,  he  thinks,  is  also  true 
of  some  cases  of  disturbed  catatonia.  In  the  latter,  he  believes 
that  the  warm  wet  pack  is  sometimes  more  practicable.  The 
patient  should  be  allowed  to  remain  in  the  pack  until  free 
sweating  results,  but  not  longer  than  two  hours. 

The  installation  of  the  permanent  warm  baths  is,  of  course, 
expensive.  They  require,  also,  the  presence  of  a  number  of  well- 
trained  attendants,  but  the  advantages  of  the  treatment  are 


454  MENTAL    DISEASES 

exceedingly  great.  The  fact  that  the  patient  becomes  quiet 
and  remains  quiet  without  the  use  of  drugs,  that  he  eats, 
sleeps,  and  can  be  nursed  \\ithout  struggling  is,  to  say  the  least, 
a  very  great  gain.  The  prolonged  immersion  is  well  borne. 
The  epithelium  may  become  somewhat  swollen  and  there  may 
be  here  and  there  some  irritation  of  the  hair-folHcles,  but  these 
are  minor  troubles  and  are  readily  treated. 

Other  methods  of  hydrotherapy  do  not  call  for  detailed  con- 
sideration. There  is  one  procedure,  however,  which  deserves 
especial  mention  and  which  I  beheve  in  given  instances  to  be 
of  great  value.  I  refer  to  the  employment  of  hypodermoclysis 
in  certain  stuporous  cases,  as  is  practised  abroad,  more  especially 
by  Pilcz,  of  Vienna.  Hypodermoclysis  is  obviously  inapplicable 
to  the  stupor  of  catatonia  or  the  stupor  of  melancholia;  it  is, 
however,  undoubtedly  applicable  to  the  stupor  of  infection  and 
exhaustion.  Here  it  unquestionably  stimulates  elimination.  I 
have  on  a  number  of  occasions  had  the  opportunity  of  emploj^- 
ing  this  method  in  such  cases  with  very  satisfactory-  effect. 
The  procedure  is  unattended  by  risk  and  should,  I  believe,  be 
more  frequentl}'  practised  than  it  is.  It  has  been  carried  out  by 
Pilcz  for  years  with  marked  success.  A  more  direct  method  is 
the  free  intravenous  injection  of  normal  salt  solution,  which  is 
sometimes  followed  by  striking  results.  In  given  instances,  as 
in  alcoholic  delirium,  the  intravenous  injection  may  be  especially 
medicated.  Here  sodium  bicarbonate  and  sodium  bromid  may 
be  added  to  the  salt  solution,  and  in  this  way  both  the  acidosis 
and  the  edema  of  the  brain  tissue  may  be  counteracted.  Hogan^ 
followed  such  an  injection  immediately  by  a  solution  of  glucose, 
the  latter  being  given  to  combat  the  exhaustion.  The  propor- 
tions used  by  Hogan  are  5.8  gm.  sodium  chlorid,  8.4gm.  sodium 

^  See  Journal  of  American  Medical  Association,  December  16th,  1916, 
p.  1826. 


TREATMENT  455 

bicarbonate,  and  10.2  gm.  sodium  bromid  in  1000  c.c.  of  water. 
The  various  substances  had  best  be  dissolved  separately  in 
freshly  distilled  water  and  boiled.  The  solution  of  glucose  is 
in  the  proportion  of  80  gm.  of  glucose  to  240  c.c.  of  water  and, 
of  course,  requires  equal  care  in  itsipreparation.  Hogan  noted 
rapid  subsidence  of  the  delirium,  while  recovery  ensued  in 
between  two  and  three  days  in  all  but  9.3  per  cent,  of  his  cases. 
The  continued  warm  bath  is  also  a  form  of  restraint;  indeed, 
it  is  the  best,  the  most  humane,  and  most  physiologic  form  of  re- 
straint yet  devised.  A  similar  function  is  served  by  the  warm 
pack.  Here  the  warmth  and  the  free  sweating  induced  are 
likewise  factors  conducing  to  the  relaxation  and  the  calming  of 
the  patient,  but,  in  addition,  the  pack  is  also  a  method  of  re- 
straint. Other  forms  of  restraint  are,  in  the  modern  asylum, 
only  infrequently  resorted  to.  However,  in  exceptional  instances, 
physical  restraint  is  imperative.  Thus,  a  patient  may  be  con- 
stantly endeavoring  to  injure  himself,  e.  g.,  to  thrust  his  nails 
into  his  eyes,  to  strike  his  head  against  the  wall — or  he  may  be 
engaged  in  a  constant  and  exhausting  struggle  with  his  surround- 
ings and  attendants.  Again,  it  may  be  that  he  has  suffered  a 
serious  surgical  injury,  such  as  a  fracture  of  a  leg,  or  perhaps 
it  has  been  necessary  to  submit  him  to  some  surgical  operation, 
the  successful  after-care  of  which  demands  quiet.  Usually  a 
sheet  or  sheets  properly  applied  answer  every  purpose.  A  sheet 
loosely  rolled  may  be  passed  back  of  the  patient's  neck  and 
under  both  armpits;  the  ends  are  then  knotted  under  the  cot 
or  securely  fastened  to  the  sides  of  the  bed.  In  a  similar  man- 
ner the  legs  may  be  fastened  by  a  rolled  sheet  which  encircles 
separately  each  ankle  and  is  then  fastened  to  either  side  of  the 
bed.  An  excellent  restraining  sheet  which  allows  considerable 
freedom  of  movement  and  yet  prevents  injury  to  the  patient 
can  be  secured  at  most  instrument  makers.    If  the  emergency 


456  MENTAL    DISEASES 

makes  it  necessary  that  a  greatly  disturbed  patient,  e.  g.,  in 
acute  mania,  be  restrained  entirely,  so  as  to  make  possible 
his  transfer  to  an  asylum  without  injury,  he  can  be  completely 
rolled  in  a  sheet,  the  arms  being  flexed  over  his  chest,  the  legs 
extended,  and  the  sheet  then  firmly  secured  by  means  of  safety- 
pins.  Such  measures  are,  however,  only  infrequently  required. 
Much  prejudice  exists  against  the  camisole — a  canvas  shirt 
with  long,  closed  sleeves  and  laced  up  the  back — and  it  can,  as 
a  rule,  be  dispensed  with.  The  same  is  true  of  anklets  and  wrist- 
lets. However,  if  properly  made  and  properly  applied,  there  can 
be  no  objection  to  their  use  under  certain  circumstances  and  in 
given  instances.  It  is  needless  to  say  that  they  should  be  removed 
as  soon  as  practicable.  It  is  important  to  point  out  that  a 
patient  under  physical  restraint  should  be  carefully  watched, 
for  it  is  quite  possible  that  he  may  injure  himself  in  spite  of  the 
restraint.  Finally,  in  cases  in  which  an  emergency  necessitates 
restraint,  we  should  not  rely  upon  this  measure  alone  to  control 
the  patient.  Sedatives  or  hypnotics  should  be  given  at  the 
same  time.     (See  p.  421.) 

In  the  management  of  the  mass  of  patients  in  an  asylum, 
general  principles,  of  course,  are  to  be  followed;  these  include 
a  Hberal  diet,  attention  to  the  digestive  tract,  the  correction  of 
constipation,  the  judicious  use,  when  necessary,  of  sedatives 
to  allay  agitation  and  the  institution  of  measures,  such  as  open 
air  exercise  and  occupation  to  combat  sleeplessness;  drugs 
should  be  used  only  at  times  and  to  tide  over  special  periods. 
Disturbed  cases  should,  of  course,  be  separated  from  the  quiet 
ones,  lest  the  latter  also  become  excited.  The  feeble  and  in- 
firm and  those  that  are  sick  naturally  require  special  attention 
and  provision.  Special  precautions,  also^  must  be  taken  in 
suicidal  cases. 


TKEATMENT  457 

As  far  as  practicable,  the  convalescent,  quiet,  and  chronic 
cases  should  be  encouraged  to  read,  to  play  games.  Light 
tasks  should  be  imposed  upon  some;  an  occupation,  gardening, 
field  work,  upon  others.  Often  patients  who  are  mischievous^ 
destructive,  or  given  to  masturbation,  are  greatly  benefited 
by  such  means.  Men  should,  when  possible,  be  interested  in 
work  to  which  they  are  accustomed;  women  in  sewing,  laundry 
work,  cooking.  Diversion  and  amusements  may  also  be  arranged, 
but  they  should  be  entered  upon  with  caution.  The  entertain- 
ments provided  should  not  be  exciting;  it  is  doubtful  whether 
balls  and  kindred  functions  have  a  place  in  the  asylum. 

By  means  of  occupation,  improved  cases  of  dementia  prsecox 
may  be  more  or  less  retrained,  and  cases  of  paranoia  become 
interested  in  something  other  than  their  delusions,  while  the 
criminal  insane  often  become  orderly  and  well  behaved. 

The  classification  and  employment  of  patients  depend  of 
course  largely  upon  the  size,  location,  and  faciUties  possible 
in  a  given  hospital.  Of  recent  years  the  tendency  has  been 
toward  the  grouping  of  patients  in  special  hospitals.  Thus, 
in  addition  to  the  general  hospitals  for  the  insane,  there  have 
been  established  hospitals  for  the  chronic  insane,  in  which  the 
patients  work  in  shops,  farms,  and  gardens;  also  hospitals  for 
the  criminal  insane,  in  which  the  patients  are  similarly  occupied; 
and,  it  is  to  be  hoped,  that  ere  long  we  will  have  adequate  hos- 
pitals for  inebriates,  in  which  the  patients  cannot  only  be 
usefully  employed,  but  also  detained.  Feeble-minded  children 
and  epileptics  are,  to  some  extent,  already  segregated  in  special 
institutions,  and  the  future  promises  that  the  high-grade 
defective  and  criminal  classes  will  also  soon  be  made  the  sub- 
jects of  a  similar  provision. 

A  method  of  caring  for  the  insane  in  families  has  long  been 
in  existence  at  Gheel  in  Belgium.     For  certain  classes  of  cases 


458  MENTAL    DISEASES 

this  plan  has  much  to  recommend  it.  Perhaps  a  useful  adapta- 
tion of  it  would  be  to  have  suitable  cases  as  they  improve  in 
the  hospital  transferred  to  famiUes  in  the  neighborhood,  so 
that  the  hospital  could  still  keep  in  touch  with  them.  If  these 
families  could  be  the  families  of  attendants  regularly  employed 
in  the  hospital  itself,  very  satisfactory  arrangements  could 
probably  be  made.  Such  a  plan  would  meet  largely  the  im- 
portant problem  of  the  "after-care"  of  the  insane,  as  well  as 
the  difficult  matter  of  judging  just  when  a  convalescent  pa- 
tient had  best  leave  the  institution.  If  he  leaves  too  soon,  he 
may  relapse;  if  he  remains  too  long,  he  may  become  discouraged 
or  indifferent.  When  practicable,  dismissed  cases  should  be 
traced  to  their  own  homes,  or  the  friends  should  be  informed 
of  the  importance  of  having  the  patient  report  to  the  hospital 
or  clinic  at  intervals. 

More  important  than  all  of  the  above  measures  is  the  founda- 
tion of  psychiatric  hospitals  in  cities  in  which  the  acutely  insane 
will  be  received  and  treated  according  to  the  most  scientific 
methods,  and  from  which  the  cases  proving  to  be  chronic  or 
incurable  may  be  distributed  to  the  appropriate  asylums. 


INDEX 


Abaissement  du  niveau  mental,  403 
Aboulia,  196 
Abscess  of  brain,  315 

symptoms,  317 
Acromegaly,  246 
Acute  Verriicktheit,  130 
Acuter  Wahnsum,  130 
Adiposis,  240 
Adolescent  insanity,   108,   113,  343. 

See  also  Dementia  praecox. 
Adrenal  disease,  247 
Adult  age,  early,  insanity  in,  343 

mature,  insanity  in,  344 
Afebrile  delirium,  34,  35,  45 

confusional   insanity   and,    dif- 
ferentiation, 49 
course  of,  46 

deliriima  tremens  and,  differen- 
tiation, 49 
diagnosis,  48 

epileptic    delirium    and,    differ- 
entiation, 48 
etiology  of,  45 

intercurrent  delirium  of  paresis 
and,  differentiation,  49 
,  pathology,  48 
prognosis,  49 
symptoms,  46 
treatment,  419 
After-care,  457,  458 
Age,  adult,  early,  insanity  in,  343 
insanity  as  related  to,  330 
mental  diseases  as  related  to,  330 
middle,  insanity  in,  344 
old,  insanity  in,  345 
Agitated  melancholia,  74 
Agoraphobia,  186 

Alcohol,     degree    of    resistance    to 
action  of,  212 
effects  of,  213 


Alcohol  in  dementia  praecox.  111 
in  production  of  inherited  neurop- 
athy, 412,  413 
AlcohoUc  confusion,  218 
confusional  insanity,  218 

prognosis,  219 
delirium,  216 

intravenous  injection  of  normal 
salt  solution  in,  454 
dementia,  223 

dementia    and,    differentiation, 

223 
paresis  and,  differentiation,  223 
prognosis,  224 
insanities,  212 

multiple  neuritis,  Korsakow's  psy- 
chosis in,  219 
paranoia,  220 
delusions  in,  221 
haUuctnations  in,  220 
prognosis  of,  222 
Alcoholism,  212 
chronic,  214 

sjonptoms  of,  214-216 
hereditary,  213 
treatment  of,  441 
AHenation,  21 
Alzheimer's  disease,  349 
autopsy,  350 
chnical  picture,  350 
physical  signs,  350 
S3Tnptoms,  349 
Amaurotic  family  idiocy,  338 
eye-grounds  in,  339 
juvenile  form,  339 
sjnnptoms,  338 
Amblyopia  in  paresis,  279 
Ameboid  pupil  in  paresis,  278 

in  tabes,  320 
Amentia^  28,  49 

459 


460 


INDEX 


Anesthesia  in  hysteria,  256,  257 
Ankle  clonus  in  paresis,  277 
Anthropophobia,  186 
Anxiety  psychoses,  185 
Apoplectiform    attacks    in    paresis, 

275,  276 
Apoplexy,  cerebral,  314 
Apperceptive  dementia,  403 
Appetite  in  dementia  pra;cox,  124 

in  mania,  91 

loss  of,  in  melancholia,  70 
Arc  de  cercle  in  hysteria,  260 
Argj'll  Robertson  pupil  in  paresis, 

280 
Arteriosclerosis,  312 

suicide  in,  313 

symptoms  of,  313 
Arthralgia,  lead,  225 
Association  in  dementia  praecox,  407 

in  hjTDomania,  94 

in  mania,  87,  88 

test  for  repressed   or  submerged 
complexes,  398 
Asylum,  commitment  to,  417 

treatment  in,  445 
outside  of,  417 
Ataxia,    locomotor,   318.      See   also 

Tabes. 
Atrophy,  optic,  in  paresis,  279 
Attention,  fault  of,  in  mania,  86 
Attitude  in  melancholia,  67 
Am-a,  psychic,  of  epilepsy,  251 
Automatism  in  confusion,  54 

in  dementia  praecox,  121 

in  stupor,  58 

Babixski's  sign  in  paresis,  277 
Bastards,  paranoia  in,  143,  144 
Bath,  warm,  452,  455 

in  afebrile  delirium,  420 
Bathing  in  treatment,  451 
Bed-sores  in  paresis,  288 
Bell's  delirium,  39 
Bestiality,  361,  362 
Blood  in  melancholia,  71 
Bones,  changes  in,  in  paresis,  289 
Borderland     manic     and     paranoid 
states,  352 


Brain,  abscess  of,  315 

symptoms,  317,  318 
atrophy  of,  336,  339 
treponema  pallidum  in,  in  paresis, 

267,  318 
tumor  of,  315 

hallucinations  in,  317 

hysteric  sjTnptoms  in,  318 

s^Tnptoms,  315-318 
Bright's  disease,  241,  242 

C.VNXER  of  stomach,  242 
Catatonia,   113,   126.     See  also  De- 
mentia prcecox. 
Catatonic  stupor,  stupor  and,  differ- 
entiation, 59 
Cerebral  apoplex>',  314 
arteriosclerosis,  313 
embolism,  314 
hemorrhage,  314 
sjTjhilis,  310 
thrombosis,  314 
Cerebrospinal  sclerosis,  multiple,  312 
paresis    and,    differentiation, 
312 
Charcot  joint  in  paresis,  290 
Childhood,  confusion  in,  332 
deUrium  in,  332 
insanity  in,  330 
suicide  in,  331 
mjocedema  in,  336 
stupor  in,  .332 
Children,  feeble-minded,  333 
duration  of  life  of,  340 
etiolog>'  of,  339 
mental  tests  in,  341 
treatment  of,  340 
hypochondria  in,  371 
nervous,   education   and   training 
of,  414,  415 
Chloralism,  236 
Chorea,  265 

Huntingdon's,  266 
Circular  form  of  paresis,  285 

insanity,  30,  62,  99 
Circulation  in  paresis,  286 
Circulatorj'  changes  in  melancholia, 
71 


INDEX 


d61 


Circulatory  disturbances  in  neuras- 
thenia, 177,  178 
in  neurasthenic-neuropathic  in- 
sanity, 183 
Classification,  26 
Claustrophobia,  186 
Cocain  bug,  235 
Cocainism,  233 

hallucinations  in,  235 

symptoms  of,  234 

treatment  of,  441,  443 
CoUc,  lead,  225 

Colloidal  gold  test  in  paresis,  304 
Coma,  diabetic,  238 
urine  in,  239 

uremic,  241 
Commitment  to  asylum,  417 
Communicated  insanity,  377 
Complexes,  repression  of,  387,388,^92 
Compulsion  neiuosis,  190 
Confusion,  27,  34,  49 

active,  50 

alcohoUc,  218 

and  deUrium,  interrelation,  29 

and  stupor,  interrelation,  29 

course  of,  52 

diagnosis  of,  55 

etiology  of,  30,  50 

forms  of,  49 

haUucinatorj^,  52 

hypnotics  in,  424 

in  childhood,  332 

in  epilepsy,  253 

in  hysteria,  261 

in  malaria,  210 

in  trauma  of  head,  322 

in  tuberculosis,  209 

nourishment  in,  424 

onset  of,  52 

passive,  50,  56 
prognosis  of,  56 

prognosis  of,  55 

senile,  346 

symptoms  of,  52 

treatment  of,  423 
Confusional  insanity,  28,  49 

afebrile    dehrium    and,    differ- 
entiation, 49 


Confusional  insanity,  alcohohc,  218 

prognosis  of,  219 
Consciousness,   double,  in  epilepsy, 

254 
Constipation  in  melanchoUa,  70 
Constitutional  emotional  depression, 

78 
Contagion,  insanity  by,  377 

prognosis,  382 
Convulsion  in  hysteria,  260 

in  paresis,  275 
Con"vulsive  tic  in  insanity   of   defi- 
cient inhibition,  192 
treatment,  440 
Cousins,  marriage  of,  414 
Cranial    nerves,    paralysis    of,    in 

paresis,  279 
Cretinism,  336 

desiccated  thyroid  in,  341 

physical  signs,  337 
Criminahty,  354 
Crj'stallophobia,  186 
Curable  dementia,  56 
Cutaneous  sensibility  in  mania,  90 

Daemmerzustand,  261 
Dauerbad,  452 
Deception  in  hj'steria,  264 
Deficienc}^,    high-grade,    states    of, 
354 
moral,  354 

sexual,  thyroid  extract  in,  363 
Deficient  inhibition,  insanity  of,  190 
coprolaUa  in,  191 
suicide  in,  195,  196 
tic  convulsif  in,  192 
tic  in,  192 
treatment,  439 
will,  insanity'  of,  196 
Definitions,  17,  20 

Degeneration,  stigmata  of,  in  etiol- 
ogy of  heboid-paranoid  group,  110 
Dehre  du  toucher,  197 
Dehres     systematises     aigus,     130, 
131,  138 
chroniques,  138 
d'emblee,  130 
Delirious  mania,  acute,  39 


462 


INDEX 


Delirium,  27,  34 
acute,  39 
afebrile,  34,  35,  45 

confusional   insanity   and,    dif- 
ferentiation, 49 
course  of,  46 

delirium    tremens    and,    differ- 
entiation, 49 
diagnosis  of,  48 

epileptic    delirium    and,    differ- 
entiation, 48 
etiology  of,  45 

intercurrent   delirium   of   pare- 
sis and,  differentiation,  49 
pathology  of,  48 
prognosis  of,  49 
sjonptoms  of,  46 
treatment  of,  419 
alcoholic,  216 

intravenous  injection  of  normal 
salt  solution  in,  454 
and  confusion,  interrelation,  29 
Bell's,  39 
definition  of,  34 
epileptic    afebrile    delirium    and, 

differentiation,  48 
etiology  of,  30 
febrile,  34,  35 
simple,  35 
course  of,  37 
diagnosis  of,  39 
etiology  of,  35 
prognosis  of,  39 
symptoms  of,  37 
specific,  39 
course  of,  40 

delirium    tremens    and,    dif- 
ferentiation, 45 
diagnosis  of,  44 
etiology  of,  40 
pathology  of,  43 
toxic  delirium  and,  differentia- 
tion, 45 
prognosis  of,  45 
symptoms  of,  40 
grave,  39 

hydrotherapy  in,  420 
hyoscin  in,  421 


Delirium,  hysteric,  260 
in  childhood,  332 
in  plumbism,  225,  226 
in  rheumatic  fever,  211 
in  trauma  of  head,  323 
nourishment  in,  423 
of  exhaustion,  45 
of   paresis,    intercurrent,    afebrile 

dehrium  and,  differentiation,  49 
paraldehyd  in,  422 
postfebrile,  45.    See  also  Delirium, 

afebrile. 
puerperal,  327 
scopolamin  in,  421 

with  morphin  in,  422 
sedatives  in,  421 
thyroid,  243 

prognosis  of,  244 
toxic,  specific  febrile  delirium  and, 

differentiation,  45 
treatment  of,  419 
tremens,  216 

afebrile  dehrium  and,  differen- 
tiation, 49 

duration  of,  218 

specific    febrile    delirium    and, 
differentiation,  45 
trional  in,  421 

with  sulphonal  in,  421 
warm  bath  in,  420 
wet  pack  in,  420 
Delusion,  definition  of,  23 
depressive,  definition  of,  24 
expansive,  definition  of,  24 
hypochondriac,  25 
in  dementia  prsecox,  407 
insane,  definition  of,  23 
of  the  unpardonable  sin,  24 

in  melanchoHa,  68 
somatic,  25 

systematized,  definition  of,  23 
unsystematized,  definition  of,  24 
Delusional   insanity,    31,    108,    138, 

139.     See  also  Paranoia. 
Delusions  in  alcohoUc  paranoia,  221 
in  dementia  prsecox,  115,  119 
in  hypomelancholia,  77 
in  mania,  89 


INDEX 


d63 


Delusions  in  melancholia,  68 
in  paranoia,  146 
in  paranoid  dementia,  127,  128 
in  paresis,  284 
Demented  form  of  paresis,  282 
Dementia,  32,  202 
acute,  28,  56 
alcoholic,  223 

dementia    and,    differentiation, 
223 

paresis  and,  differentiation,  223 

prognosis  of,  224 
curable,  56 
definition  of,  202 
epUeptic,  247 
in  malaria,  210 
lead,  224,  226 
paralytic,  266 
paranoid,  113,  114,  127 

course  of,  129 

delusions  in,  127,  128 

depression  in,  129 

duration  of,  136,  137 

hallucinations  in,  127,  129 

prognosis  of,  130,  131,  136 

suicide  in,  128 
paretic,  266 
precox,  31,  108,  113 

absence  of  psychic  reflex  in,  124 

alcohol  in,  111 

appetite  in,  124 

associations  in,  407 

automatism  in,  121 

before  puberty,  331 

cases  of,  in  family,  109 

catatonic    form,    distinguishing 
features,  126 
prognosis  of,  130,  134,  135  . 

clinical  pictures,  forms  of,  138 

course,  114 

delusions  in,  115,  119,  407 

depression  in,  116 

enlargement  of  thjo-oid  gland  in, 
124 

expansive  period  in,  116,  117 

Freud's     repressed     complexes 
in  interpretation  of,  406 

germ  plasm  in,  111,  130 


Dementia  prsecox,  hallucinations  in, 
116,  406 
hebephrenic   form,    distinguish- 
ing featm-es,  125 
prognosis  of,  130,  134,  135 
insomnia  in,  124 
masturbation  in,  123 
memory  in,  120 
mental  impairment  in,  118 
negativism  in,  121 
nerve  substance  in,  408 
number  of  cases  in  family,  109 
'    paranoid  form,  127 
course  of,  129 
delusions  in,  127,  128 
depression  in,  129 
duration  of,  136 
hallucinations  in,  127,  129 
prognosis  of,  130,  131,  136 
suicide  in,  128 
physical  signs,  123 
prognosis,  130 
psychology  of,  402 
pupils  in,  123 
sex  glands  in,  131,  132 
simple  form,  distinguishing  fea- 
tures, 125 
symptoms,  114 
syphilis  in.  111 
transmission  of,  109 
treatment  of,  433 
verbigeration  in,  122 
Wassermann  reaction  in,  111 
primary,  202 
secondary,  105,  202 
senile,  203,  345 

senile  melancholia  and,   differ- 
entiation, 351 
symptoms  of,  203 
terminal,  105 

as  result  of  stupor,  60 
Depression,  constitutional  emotional, 
78 
in  dementia  praecox,  129 
in  paranoid  dementia,  129 
of  mental  level,  403 
period  of,  in  mania,  83 
in  mystic  paranoia,  156 


464 


INDEX 


Depressive   delusion,    definition    of, 
24 

form  of  paresis,  283 
Desiccated  thjToid  in  cretinism,  341 
Deviation  and  arrest,  stigmata  of,  in 

etiology  of  heboid-paranoid  group, 

110 
Diabetes,  238 
Diabetic  coma,  238 

urine  in,  239 
Digestion  in  mania,  91 

in  paresis,  287 
Digestive    disturbances    in    neuras- 
thenia, 177 
in  neurasthenic-neuropathic  in- 
sanities, 183 
Diplegic  idiocy,  335 
Dipsomania,  193,  197 
Dissociation,  384 
Dormeh,  157 
Double  consciousness  in  epilepsy,  254 

personality  in  hysteria,  262-265 
Dream-displacement,  395 
Dreams    in    production    of    mental 
symptoms,  394 

psychology  of,  397 

therapeutic  application  of,  396 
Ductless  glands,  diseases  of,  243 
Doukhobors,  158 
Dysthyroidism,  243 

Ear,  hematoma  of,  in  paresis,  289 
Embohsm,  314 
Encephalopathy,  lead,  225 
Enema,    nutritive,    in    melancholia, 

432 
Enlargement    of    thyroid    gland    in 

dementia  pra?cox,  124 
Epilepsy,  247 

confusion  in,  253 

double  consciousness  in,  254 

duration  of  attack,  252 

episodic  mental  states  in,  250 

etiology  of,  247 

hallucinations  in,  252 

larvated,  251,  252 

morphological    arrest    and    devia- 
tion in,  248 


Epilepsy,  nocturnal,  253 
psychic,  251,  252 
aura  of,  251 
prodromata  of,  251 
sequela?  of,  251 
somnambuhsm  of,  253 
stupor  in,  253 
symptoms  of,  248,  249 
Epileptic  dehrium,  afebrile  delirium 
and,  differentiation,  48 
dementia,  247 
Epileptiform  attacks  in  paresis,  275 
Episodic  mental  states  in  epilepsy, 

250 
Erotic  symptoms  in  paranoia  sim- 
plex, 166 
Euphoria  in  tuberculosis,  209 
Exhaustion,  delirium  of,  45 
Exophthalmic  goiter,  243,  244 

symptoms  of,  243 
Expansive  delusion,  definition  of,  24 
form  of  paresis,  284 
period  in  dementia  praecox,   116, 
117 
Extramural  treatment,  417 
Eye  symptoms  in  juvenile  paresis, 
280,  281 
of  paresis,  277 
Eye-ground,   changes  in,  in  paresis, 
279 
in  amaurotic,  family  idiocy,  339 

Facial  appearance  in  paresis,  274, 

276 
Family,  dementia  prsecox  in  number 
of  members  of,  109 
idiocy,  amaurotic,  338 
Fatigue  in  neurasthenia,  176 

neurosis,  175,  181 
Fear    in    neurasthenia,     178,     180, 
181 
of  open  spaces,  186 
Fears,  special,  insanity  of,  185 
etiology,  187 

masturbation  and,  187,  188 
sexual  trauma  in  etiology  of, 
187,  188 
Febrile  delirium,  34,  35 


INDEX 


465 


Febrile  delirium,  simple,  35 
course  of,  37 
diagnosis  of,  39 
etiology  of,  35 
prognosis  of,  39 
symptoms  of,  37 
specific,  39 
course  of,  40 

delirium  tremens  and,  differ- 
entiation, 45 
diagnosis  of,  44 
etiology  of,  40 
pathology  of,  43 
prognosis  of,  45 
symptoms  of,  40 
toxic    delirium    and,    differ- 
entiation, 45 
Feeble-minded  children,  333 
duration  of  Uf e  of,  340 
etiology  of,  339 
mental  tests  in,  341 
treatment  of,  340 
Feeding,  forcible,  in  melancholia,  429 

fuU,  in  treatment,  448 
Fetichism,  362,  363 
Fohe  d  deux,  380 
communiquee,  380 
du  doute,  188,  197 
Foot,  perforating  ulcer  of,  in  pare- 
sis, 288 
Forcible  feeding  in  melancholia,  429 
Frenzy,  melanchoHc,  74 
Freud,  389 
Functional  nervous  diseases,  247 

'  Gait  in  paresis,  277 
Gastro-intestinal  form  of  hypochon- 
dria, 375 
General  paralysis  of  insane,  267 
progressive,  267 
paresis,  267 
Glands,  ductless,  diseases  of,  243 
Globuhn  test  in  paresis,  302,  303 
Goiter,  exophthalmic,  243,  244 

sjTnptoms  of,  243 
Gold  test,  colloidal,  in  paresis,  304 
Gout,  240 

hallucinations  in,  240 
30 


Grave  dehrium,  39 
Gruebelsucht,  188 

Hallucination,  definition  of,  22 
Hallucinations  in  alcohoUc  paranoia, 
220 
in  cocainism,  234 
in  deUrium  tremens,  217 
in  dementia  praecox,  116,  406 
in  epUepsy,  252 
in  gout,  240 
in  mania,  89 

in  melancholia,  69,  70,  77 
in  paralysis  agitans,  266 
in  paranoia,  144,  145 

simplex,  160 
in  paranoid  dementia,  127,  128 
in  paresis,  283 
in  plumbism,  225 
in  puerperal  dehrium,  328 
in  rheumatic  fever,  211 
in  tumor  of  brain,  317 
of  hearing  in  paranoia,  145 

simplex,  165 
of  poisoning  in  paranoia,  147 
of  sight  in  paranoia  simplex,  165 
of  smeU  in  paranoia,  147 
of  taste  in  paranoia,  147 

simplex,  165 
of  vision  in  mystic  paranoia,  155 
in  paranoia,  148 
simplex,  165 
sexual,  in  mystic  paranoia,  155 

in  paranoia  simplex,  166 
visceral,  in  paranoia,  144,  147 
Hallucinatorische  Verwirtheit,  52 
Hallucinatory  confusion,  52 
paranoia,  138,  141,  143 
prognosis  of,  172 
treatment,  433 
Handwriting  in  paresis,  281 
Head,  trauma  of,  321 
confusion  in,  322 
delirium  in,  323 
Hearing,  hallucinations  of,  in  mel- 
anchoUa,  69 
in  paranoia,  145 
simplex,  165 


466 


INDEX 


Heart,    palpitation    of,    in    neuras- 
thenia, 178,  180 
in  neurasthenic-neuropathic  in- 
sanity, 183 
Hebephrenia,    113,    125.      See    also 

Dementia  prcecox. 
Heboid-paranoia,  129 
Heboid-paranoid  affections,  31,  108 
heredity  in  etiology  of,  108 
stigmata  of  deviation  and  arrest 
in  etiology  of,  1 10 
Hematoma  of  ear  in  paresis,  289 
Hemianesthesia  in  hysteria,  256,  262 
Hemiplegia  in  paresis,  275 
Hemiplegic  idiocy,  335 
Hemorrhage,  314 

Hemorrhagic  pachj'meningitis  in  pa- 
resis, 289 
Hereditary  alcoholism,  213 

factors  in  hypochondria,  366 
Heredity    in    etiology    of    heboid- 
paranoid  group",  108 
of  paranoia,  141 
High-grade  deficiency,  states  of,  354 
History,  17 

Homosexual  love,  360,  410 
Huntingdon's  chorea,  266 
Hutchinson's  \)u\n\  in  head  injury, 

322 
Hj'drocephalus,  336 
Hydrotherapy  in  deUrium,  420 
Hj^oscin  in  delirium,  421 
Hyperesthesia  in  hysteria,  256 
Hyperpinealism,  247 
Hyperthyroidism,  243,  447 
Hypesthesia  in  hysteria,  256 
Hypochondria,  363 

anxiety  of  patient  in,  369 

course  of,  374 

etiology  of,  366 

gastro-intestinal  form,  375 

hereditary  factors  in,  366 

hysteria  and,  differentiation,  254 

in  childhood,  368 

melanchoUa   and,    differentiation, 
366 

physical  signs,  370 

sex-ual  form,  375,  376 


Hypochondria,  symptoms  of,  364, 365 

premonitory,  368 
Hypochondriac  delusion,  25 

mental  make-up  of,  375 
Hypochondriacal  form  of  paranoia, 

152 
Hypodermoclysis    in    treatment    of 
stu])or  cases,  454 

of  salt  solution  in  melaricholia,  432 
Hypomania,  93 

association  in,  94 

course  of,  94,  98 

diagnosis  of,  98 

ideas  in,  increased  flow  of,  94 

in  middle  age,  344 

memory  in,  95 

nourishment  in,  427 

paranoia  and,  differentiation,  98 

paresis  and,  differentiation,  98 

physical  signs,  98 

prognosis  of,  99 

sexual  instincts  in,  95 

symptoms  of,  94 

treatment  of,  426 
Hypomclancholia,  76 

delusions  in,  77 

duration  of,  77 

I)rognosis  of,  77,  78 

suicide  in,  78 

symptoms  of,  76,  77 
Hypopinealism,  247 
HypothjToidism,  243,  447 
Hystera,  255 
Hysteria,  254 

anesthesia  in,  256,  257 

arc  de  cercle  in,  260 

confusion  in,  261 

contagiousness  of,  377 

convulsion  in,  260 

deception  in,  264 

definition  of,  255 

delirium  in,  261 

double  personality  in,  262-265 

hemianesthesia  in,  262 

hyperesthesia  in,  256 

hypesthesia  in,  256 

hypochondria  and,  differentiation, 
254 


INDEX 


467 


Hysteria,  inframammary  tenderness 
in,  257 

inguinal  tenderness  in,  257 

neurasthenia  and,  diiferentiation, 
254 

opisthotonos  in,  260 

ovarian  tenderness  in,  257 

paroxysm  of,  259 
duration,  261 

psychasthenia     and,     differentia- 
tion, 255 

somnambuUsm  in,  263 

spinal  tenderness  in,  257 

stupor  in,  261 

suggestion  in,  262 
in  production  of  symptoms  of, 
259 

symptoms  of,  256,  257 
motor,  257 
pyschic,  258 
sensory,  256 
somatic,  257 

suggestion  in  production  of,  259 
visceral,  257 

treatment  of,  440 

tumor  of  brain  and,   differentia- 
tion, 318 

Ideas,  increased  flow  of,  in  hypo- 
mania,  94 
in  mania,  87,  88 
Idiocy,  333 

amaurotic  family,  339 

classification  of,  333,  334 

deanition  of,  21 

diplegic,  335 

hemiplegic,  335 

learned,  343 

Mongolian,  335 

moral,  357 

morphologic,  334 

pathologic,  335 

treatment  of,  340 
Idiots  savants,  343 
Illusion,  definition  of,  22 
Imbecihty,  333 

definition  of,  21 

treatment  of,  340 


Impotence,  psychic,  376 
Impulses  in  mania,  85 

in  pyromania,  193 
Impulsions,  190 

treatment  of,  439 
Impulsive  movements,  190 
treatment  of,  439 
tendencies,  190 
Incoherence  in  mania,  88 
Incomplete  stupor,  60 
course,  61 
prognosis,  61 
symptoms,  60 
Indecision,  insanity  of,  188 
Indigestion  in  neurasthenia,  177 
Infancy,  insanity  in,  330 
Infectious  diseases,  207 
Inframammary   tenderness   in   hys- 
teria, 257 
Inguinal  tenderness  in  hysteria,  257 
Inhibition,  deficient,  insanity  of,  190 
coprolalia  in,  191 
suicide  in,  195,  196 
tic  convulsif  in,  192 
tic  in,  192 
treatment,  439 
Injuries  of  head,  321 
Insane  delusion,  definition,  23 

general  paralysis  of,  267 
Insanity,  adolescent,  108,  113.     See 
also  Dementia  proecox. 
alcohohc,  212 
confusional,  218 
prognosis  of,  219 
as  related  to  age,  330 
by  contagion,  377 

prognosis,  382 
circular,  30,  62,  99 
classification  of,  26 
communicated,  377 
confusional,  28,  49 

afebrile    delirium    and,    differ- 
entiation, 49 
alcoholic,  218 
prognosis  of,  219 
definition  of,  17,  20 
delusional,  31,  108,  132,  138,  139. 
See  also  Paranoia. 


468 


INDEX 


Insanity,  heboid-paranoid  group,  31, 
108 
heredity  in  etiology  of,  108 
stigmata  of   degeneration  in 
etiology  of,  110 
history  of,  17 
in  childhood,  330 
suicide  in,  331 
in  early  adult  age,  343 
in  infancy,  330 
in  mature  adult  age,  344 
in  middle  age,  344 
in  old  age,  345 
juvenile,  31,  108,  113.      See  also 

Dementia  proecox. 
lead,  224 

manic-depressive,  31,  62,  101 
pathology  of,  106 
prognosis  of,  101 
moral,  357 

neurasthenic,  32,  175 
course  of,  197 
prognosis  of,  197 
treatment  of,  434 
neurasthenic-neuropathic,  32,  175 
circulatory  disturbances  in,  183 
course  of,  197 

digestive  disturbances  in,  183 
forms  of,  185 
inadequacy  in,  184 
palpitation  of  heart  in,  183 
prognosis  of,  197 
sexual  disturbances  in,  184 
suicide  in,  195,  196 
symptoms  of,  183 
physical,  183 
psychic,  184 
thyroid  insufficiency  in,  184 
treatment  of,  434 
of  adolescence,     108,     113,     343. 

See  also  Dementia  prcBCox. 
of  deficient  inhibition,  190 
coprolaUa  in,  191 
suicide  in,  195,  196 
tic  convulsif  in,  192 
tic  in,  192 
treatment  of,  439 
will,  196 


Insanity  of  double  form,  99 
of  indecision,  188 
of  special  fears,  185 
etiology  of,  187 
masturbation  and,  187,  188 
sexual  trauma  in  etiology  of, 
187,  188 
partial,  138,  139.      See  also  Par- 
anoia. 
periodic,  99 
precocious,  108 
psychology  of,  383 
stuporous,  28,  56 
symptoms  of,  19 
with  irresistible  impulse,  190 
Insomnia  in  dementia  praecox,  124 
in  mania,  89 
in  neurasthenia,  177 
Intoxications,  212 
by  alcohol,  212 

treatment,  441 
by  chloral,  236 
by  cocain,  233 

treatment  of,  441,  443 
by  lead,  224 
by  medinal,  237 
by  morphia,  227 

treatment  of,  441-444 
by  opium,  227 

treatment  of,  441-444 
by  paraldehyd,  237 
by  sulphonal,  237 

treatment  of,  441 
by  trional,  237 
by  veronal,  237 
Intracranial  pressure,  increased,  in 

paresis,  282 
Intramural  treatment,  445 
Intraspinal    pressure,    increased,    in 

paresis,  282 
Involution,  melancholia  of,  344 
lodids  in  paresis,  304 
Irresistible  impulse,  insanity  with,  190 
Irritability  in  neurasthenia,  180 

Joints,  changes  in,  in  paresis,  289, 
290 
Charcot,  in  paresis,  289,  290 


INDEX 


469 


Juvenile  form  of  amaurotic  family 

idiocy,  339 
insanity,  31,  108,   113.     See  also 

Dementia  prcEcox. 
paresis,  270 

eye  symptoms,  280,  281 

Katatonia,  113,  126.    See  also  De- 
mentia prcecox. 
Kleptomania,  193,  197 
Knee-jerks  in  paresis,  277 
Korsakow's  psychosis,  219,  220 

Labor,  324 

Lactation,  324,  329 

Lange's  colloidal  gold  test  in  paresis, 

304 
Larvated  epilepsy,  251,  252 
Lavage  of  stomach  in  melancholia, 

432 
Lead  coUc,  224 

dementia,  224,  226 

encephalopathy,  225 

insanities  due  to,  224 

paralysis,  225 

poisoning,  224 

rheumatism,  225 
Learned  idiots,  343 
L'6cHpse  mentale,  199 
Light  reflex  in  paresis,  278,  280 
Little's  disease,  336 
Locomotor   ataxia,   318.     See   also 

Tabes. 
Lucid  melancholia,  79 
Lucidity  in  paranoia  simplex,  165 
Luminal,  421 

sodium,  422,  453 
Lymphocytosis  in  paresis,  302,  303 

Malaria,  209 

confusion  in,  210 

dementia  in,  210 

prognosis  of,  210 
Malarial  paresis,  210 
Malignant  disease,  241,  242 
Mania,  30,  62,  81 

appetite  in,  91 

associations  in,  87,  88 


Mania,  attention  in,  fault  of,  86 

course  of,  82 

cutaneous  sensibility  in,  90 

decHne  of  symptoms,  92 

definition  of,  81 

delirious  acute,  39 

delusions  in,  89 

depression  in,  83 

diagnosis  of,  92 

digestion  in,  91 

duration  of  attack,  92 

etiology  of,  82 

fault  of  attention  in,  86 

hallucinations  in,  89 

hallucinatoria,  52 

ideas   in,    increased   flow    of,   87, 
88 

illusions  of  perception  in,  86 

impulses  in,  85 

incoherence  in,  88 

insomnia  in,  89 

masturbation  in,  90 

memory  in,  92 

menstruation  in,  92 

mental  attitude  in,  85 

muscular  efforts  in,  90 

period  of  depression  in,  88 

perspiration  in,  91 

physical  signs,  90 

prognosis  of,  93,  101 

puerperal,  327 

pulse  in,  91 

saHva  in,  increase  of,  91 

secretions  in,  91 

senile,  347,  351 

special  senses  in,  91 

state  of  mind  in,  84 

subacute  form,  93 

symptoms  of,  82 

temperature  in,  91 

thoughts  in,  85,  87 

urine  in,  91 
Manic  state,  84 

states,  borderland,  352 
Manic-depressive   insanity,   31,    62, 
101 
pathology,  106 
prognosis,  101 


470 


INDEX 


Marriage  in   neuropathic   ancestry, 
413,  414 
of  cousins,  414 
Masochism,  361 
Massage  in  treatment,  451 
Masturbation  in  dementia  praecox, 
123 
in  mania,  90 

special  fears  and,  187,  188 
Mattoids,  352 
Medicinal  intoxication,  237 
Melancholia,  30,  62,  64 
agitata,  74 
course,  75 
diagnosis,  75 
duration,  75 

paranoia  and,  differentiation,  75 
prognosis,  75 
appearance  of  paranoid  attitude 

in,  105 
appetite  in,  loss  of,  70 
attitude  in,  67 
attonita,  79,  81 
blood  in,  71 

circulatory  changes  in,  71 
constipation  in,  70 
contagiousness  of,  381 
course  of,  65 
definition  of,  64 

delusion  of  unpardonable  sin  in,  68 
delusions  in,  68 
etiology  of,  65 
forcible  feeding  in,  429 
hallucinations  in,  69,  70,  77 
hypochondria  and,  differentiation, 

3.66 
hypodermoclysis  of  salt  solution 

in,  432 
lavage  of  stomach  in,  432 
loss  of  appetite  in,  70 

of  weight  in,  71 
lucid,  79 

nasal  feeding  in,  430 
nourishment  in*  429 
nursing  in,  428,  429 
nutritive  enema  in,  432 
of  involution,  104,  344 
prognosis  of,  101 


Melancholia,  psychic  pain  in,  67 
pulse-rate  in,  71 
respiration  in,  71 
senile,  351 

senile  dementia  and,  differentia- 
tion, 351 
sine  dehrio,  79 
sitiophobia  in,  71 
skin  in,  71 
starvation  in,  73 

stuporous,    stupor   and,    differen- 
tiation, 59 
subacute  form,  76 
suicide  in,  72 

prevention  of,  428 
symptoms  of,  65 
temperature  in,  71 
treatment  of,  426,  427 
urine  in,  71 
visceral  signs  of,  70 
with  agitation,  74 
course,  75 
diagnosis,  75 
duration,  75 
paranoia  and,  differentiation, 

75 
prognosis,  75 
with  stupor,  79 
duration,  81 
prognosis,  81 
symptoms,  79,  80 
without  delusions,  78 
course  of,  79 
duration,  79 
suicide  in,  79 
worry  in,  66 
Melancholia-mania,  30,  31,  62 
frequency  of,  63 
pathology  of,  106 
Melancholic  frenzy,  74 

stupor,    stupor    and,    differentia- 
tion, 59 
Memory'  in  dementia  praecox,  120 
in  hypomania,  95 
in  mania,  92 
Menstruation  in  mania,  92 
Mental  attitude  in  mania,  85 
diseases  as  related  to  age,  330 


INDEX 


471 


Mental  exhaustion  in  neurasthenia, 
179 
weakness,  198 
Mercury  in  paresis,  310 
MetaboUsm,  disorders  of,  237 
Middle  age,  hypomania  in, '344 

insanity  in,  344 
Mind,  state  of,  in  mania,  84 

weakness,  198 
Mongolian  idiocy,  335 
Monomania,  138,  139.         See  also 

Paranoia. 
Monophobia,  186 
Moral  deficiency,  354 
idiocy,  357 
insanity,  357 
Morons,  354 

Morphinism,  227  * 

symptoms  of,  228 

when  poison  is  withdrawn,  230, 
231 
treatment  of,  441-444 
Morphologic  idiocy,  334 
Morphological  arrest  and  deviation 

in  epilepsy,  248 
Multiple      cerebrospinal      sclerosis, 
312 
paresis    and,    differentiation, 
312 
neuritis,     alcoholic,     Korsakow's 
psychosis  in,  219 
Muscular  changes  in  paresis,  289 
efforts  in  mania,  90 
exhaustion  in  neurasthenia,  176 
strength  in  paresis,  276 
■  Myokymia  in  neurasthenia,  177 
Mysophobia,  187 
Mystic  paranoia,  154 

hallucinations  of  vision  in,  155 
period  of  depression  in,  156 
sexual  hallucmations  in,  155 
Myxedema,  245 
in  children,  336 
symptoms  of,  245,  246 

Nasal  feeding  in  melancholia,  430 

Necrophily,  361 

Negativism  in  dementia  pr^ecox,  121 


Nerve  substance  in  dementia  prsecox, 

408 
Nervous    children,    education    and 

training  of,  414,  415 
diseases,  247 

functional,  247 

organic,  266 
prostration,  175.      See  also  Neu- 
rasthenia. 
Neurasthenia,  175 

circulatory  disturbances  in,    177, 

178 
definition  of,  25 
digestive  disturbances  in,  177 
fatigue  in,  176 
fear  in,  178,  ISO,  181 
hysteria  and,  differentiation,  254 
indigestion  in,  177 
insomnia  in,  177 
irritability  in,  180 
mental  exhaustion  in,  179 
muscular  exhaustion  in,  176 
myokymia  in,  177 
palpitation  of  heart  in,  178,  180 
paresis  and,  differentiation,  271 
pulse  in,  178 
rest  cure  in,  434 
sexual  disturbances  in,  178,  179 
symptoms  of,  176 

motor,  176 

psychic,  179 

sensory,  177 

somatic,  177 
tachycardia  in,  178,  180 
treatment  of,  434 
Neurasthenic,  definition  of,  25 
insanities,  32,  175 

course,  197 

prognosis  of,  197 

treatment  of,  434 
Neurasthenic-neuropathic  disorders, 
32,  175 

circulatory  disturbances  in,  183 

course  of,  197 

digestive  disturbances  in,  183 

forms  of,  185 

inadequacy  in,  184 

palpitation  of  heart  in,  183 


472 


INDEX 


Neurasthenic-neuropathic  disorders, 
prognosis  of,  197 
symptoms  of,  psychic,  184 
sexual  disturbances  in,  184 
suicide  in,  195,  196 
symptoms  of,  183 

physical,  183 
th>Toid  insufficiency  in,  184 
treatment  of,  434 
Neuritis,    multiple,    alcoholic,    Kor- 

sakow's  psychosis  in,  219 
Neuropathic,  definition  of,  25 
Neuropathy,  definition  of,  25 
Neurosis,  compulsion,  190 

fatigue,  175,  181 
Nocturnal  epilepsy,  253 
Noguchi's  discovery  in  paresis,  267, 

318 
Nonne  globuhn  test  in  paresis,  302, 

303 
Nosophobia,  188 
Nourishment  in  confusion,  424 
in  deUrium,  423 
in  dementia  prsecox,  433 
in  h>T)omania,  427 
in  melanchoUa,  428 
in  neurasthenia,  434 
in  neurasthenic  insanities,  434 
in  psychasthenias,  434 
in  stupor,  425 
Nursing  in  melanchoUa,  428,  429 

of  insane,  insanity  from,  382 
Nutritive    enema     in     melancholia, 

432 
Nyctophobia,  186 

Obsessions  with  irresistible  tenden- 
cies, 190 
Old  age,  insanity  in,  345 
Open  spaces,  fear  of,  186 
Opisthotonos  in  hysteria,  260 
Opium  poisoning,  227 

treatment  of,  441-444 
Optic  atrophy  in  paresis,  279 
Organic  ner^'ous  diseases,  266 
Originare  \'errucktheit,  332 
Ovarian    tenderness     in      hysteria, 
257 


Pachymeningitis  hemorrhagica  in 

paresis,  289 
Pack,  wet,  in  afebrile  delirium,  420 
Pain  in  paresis,  272 

psychic,  in  melancholia,  67 
Palpitation  of  heart  in  neurasthenia, 
178,  ISO 
in  neurasthenic-neuropathic  in- 
sanity, 183 
Paraldehyd  in  delirium,  422 

intoxication,  237 
Paralysis  agitans,  266 
hallucinations  in,  266 
general,  of  insane,  267 
lead,  225 

of  cranial  nerves  in  paresis,  279 
progressive  general,  267 
Paralytic  dementia,  267 
Paranoia,  31,  108,  138 
acute,  130,  132 
alcoholic,  220 
delusions  in,  221 
hallucinations  in,  220 
prognosis  of,  222 
auditory  hallucinations  in,  145 
combinatorische  form,  140 
course  of,  143 
definition  of  term,  139 
delusions  in,  146 
forms  of,  140,  143 
frequency  of,  143 
in  bastards,  143 
in  persons  born  out  of  wedlock, 

143 
in  unmarried,  143 
hallucinations  in,  144,  145 
of  hearing  in,  145 
of  poisoning  in,  147 
of  smell  in,  147 
of  taste  in,  147 
of  vision  in,  148 
hallucinatory',  138,  140,  143 
chronic,  140 
prognosis  of,  172 
treatment  of,  433 
heboid-,  129 

heredity  in  etiology  of,  141 
hypochondriacal  form,  152 


INDEX 


473 


Paranoia,  h5T)omama  and,  differen- 
tiation, 98 
in  bastards,  143 

melancholia    agitata    and,    differ- 
entiation, 75 
mystic,  154 

hallucinations  of  vision  in,  155 
period  of  depression  in,  156 
sexual  hallucinations  in,  155 
non-haUucinatory,  140,  159.     See 

also  Paranoia  simplex. 
of  Utigation,  169 
originaria,  332 
period  of  persecution  in,  141,  149, 

150 
persecutory  phase,  141,  149,  150 
phantastic  form,  140 
predisposition  to,  141,  143 
prognosis  of,  172 
psychology  of,  409 
secondary,  105 
self-accusatory  form,  152 
senile,  347 
simplex,  159 

erotic  symptoms  in,  166 
hallucinations  in,  160 

of  hearing  in,  165 
of  sight  in,  165 
of  taste  in,  165 
lucidity  in,  165 
onset  of,  161 
prognosis,  172 

sexual  haUucinations  in,  166 
symptoms  of,  160,  161 
treatment  of,  433,  434 
skull  in,  shape  of,  142 
symptoms  of,  143 
treatment  of,  433 
visceral  haUucinations  in,  144,  147 
Paranoid  attitude,  appearance  of,  in 
melanchoHa,  105 
dementia,  113,  114,  127 
course  of,  129 
delusions  in,  127,  128 
depression  in,  129 
duration,  136 
haUucinations  in,  127,  129 
prognosis,  130,  131,  136 


Paranoid  dementia,  suicide  in,  128 

states,  borderland,  352 
Paresis,  266 

age  occurring,  270 

alcohoUc  dementia  and,  differen- 
tiation, 223 

amblyopia  in,  279 

ameboid  pupU  in,  278 

ankle  clonus  in,  277 

apoplectiform  attacks  in,  275,  276 

Arg^-U  Robertson  pupU  in,  280 

Babinski's  sign  in,  277 

bed-sores  in,  288 

bone  changes  in,  289 

changes  in  ej-e-ground  in,  279 

Charcot  joint  in,  289,  290 

circular  form,  285 

circulation  in,  286 

coUoidal  gold  test  in,  304 

convulsions  in,  275 

com-se  of,  270 

delirium  of,  intercurrent,  afebrile 
dehrium  and,  differentiation,  49 

delusions  in,  283 

depressive  form,  283 

diagnosis  of,  300 

digestion  in,  287 

distribution,  geographic,  269 

dxn-ation  of,  290,  292 
epileptiform  attacks  in,  275 
etiology  of,  267 
sjT5hihs,  267 
expansive  form,  284 
eye-ground  in,  changes  in,  279 

symptoms,  277 
facial  appearance  in,  274,  276 
forms  of,  282 
gait  in,  277 
general,  267 

geographic  distribution,  269 
globulin  test  in,  302,  303 
gold  test,  coUoidal,  in,  304 
hallucinations  in,  283 
handwriting  in,  281 
hematoma  of  ear  in,  289 
hemiplegia  in,  275 
hypomania    and,    differentiation, 
98 


474 


INDEX 


Paresis,  increased  intracranial  pres 
sure  in,  282 

intraspinal  pressure  in,  282 
iodids  in,  304,  310 
joint  changes  in,  289,  290 
juvenile,  270 

eye  sjTnptoms,  281 
knee-jerks  in,  277 
light  reflex  in,  278,  280 
lymphocytosis  in,  302,  303 
malarial,  210 
mercury  in,  310 
multiple     cerebrospinal     sclerosis 

and,  differentiation,  312 
muscular  changes  in,  289 

strength  in,  276 
neurasthenia  and,  differentiation, 

271 
Nonne  globulin  test  in,  302,  303 
optic  atrophy  in,  279 
pachymeningitis  hsemorrhagica  in, 

289 
pain  in,  272 

paralysis  of  cranial  nerves  in,  279 
pathology  of,  294 
perforating  ulcer  of  foot  in,  288 
physical  signs,  274 
pleocytosis  in,  302,  303 
prognosis  of,  293 
progress  of,  rate,  290 
pseudo-,  311 
pulse  in,  287 

pupils  in,  278,  279,  280,  281,  320 
rate  of  progress,  290 
remission  of  symptoms,  290 
respiration  in,  287 
rest  in  treatment  of,  444 
saliva  in,  287 
salvarsan  in,  305-310 
seizures  in,  276 
sex  frequency,  270 
simple  demented  form,  282 
skin  in,  287 

speech  disturbances,  281 
stages  of,  271 
susceptibility  to,  269 
sway  of  body  in,  277 
sweating  in,  287 


Paresis,  symptoms  of,  270 
physical,  274 
sensory,  282 
visceral,  286 
syphihs  in  etiology  of,  267 
in  pathology  of,  294,  295 
tabes  and,  differentiation,  319 
tabo-,  290 
temperature  in,  288 
treatment  of,  305,  444 
tremor  in,  276 
treponema  pallidum  in  brains  in, 

267,  318 
trophic  disturbances  in,  288 
unsalvarsanized  serum  in,  308 
urine  in,  287 
visceral  symptoms,  286 
Wassermann  reaction  in,  267,  302, 

304 
weight  in,  287 
Paretic  dementia,  267 
Paretics,    discovery    of    treponema 

pallidum  in  brains  of,  267,  318 
Paroxysm  of  hysteria,  259 

duration,  261 
Partial  insanity,  138,  139.     See  also 

Paranoia. 
Parturition,  324 
Passive  confusion,  50,  56 

prognosis,  56 
Pathologic  idiocies,  335 
Pederasty,  362 
Pellagra,  210 

suicide  in,  211 
Perception,  illusions  of,  in  mania,  86 
Perforating  ulcer  of  foot  in  paresis, 

288 
Periodic  insanity,  99 
Persecution,  period  of,  in  paranoia, 

141,  149,  15Q 
Personality,  double,  in  hysteria,  262- 
265 
transformation  of  the,  141 
Perspiration  in  mania,  91 
Perversion,  sexual,  358,  362 

prognosis  of,  363 
Phobias,  185 
Pineal  gland,  diseases  of,  247 


INDEX 


475 


Pithiatism,  254,  258.    See  also  Hys- 
teria. 
Pituitary  deficiency,  247 

gland,  diseases  of,  246 
Pleocytosis  in  paresis,  302,  303 
Plumbism,  224 

delirium  in,  225,  226 

hallucinations  in,  225 

prognosis  of,  227 
Poisoning,  alcohol,  212 
treatment  of,  441 

chloral,  236 

cocain,  233 

treatment  of,  441-444 

hallucinations  of,  in  paranoia,  147 

lead,  224 

medinal,  237 

morphia,  227 

treatment  of,  441-444 

opium,  227 

treatment  of,  441-444 

paraldehyd,  237 

sulphonal,  237 

trional,  237 

veronal,  237 
Postfebrile  delirium,   45.     See  also 

Delirium,  afebrile. 
Precocious  dementia,  108,  113.    See 

also  Dementia  proecox. 
Pregnancy,  324 

as  cause  of  dementia  prsecox,  326 
Preventive  treatment,  412 
Prodromata,  psychic,  of  epilepsy,  251 
Progressive  general  paralysis,  267 
Pseudo-paresis,  311 
Psychalgia,  67 
Psychanalysis,  389,  390 
Psychasthenia,  32,  175,  198 

hysteria  and,  differentiation,  255 

treatment  of,  434 
Psychic  aura  of  epilepsy,  251 

epilepsy,  251,  252 

impotence,  376 

pain  in  melanchoha,  67 

prodromata  of  epilepsy,  251 

reflex,    absence    of,    in    dementia 
prsecox,  124 

sequelae  of  epilepsy,  251 


Psychologic  interpretation  of  symp- 
toms, 383 
Psychology  of  dementia  prsecox,  402 

of  dreams,  397 

of  insanity,  383 

of  paranoia,  409 
Psychoses,  anxiety,  185 
Psychosis,  Korsakow's,  219,  220 
Puerperal  dehrium,  327 

insanity,  324 

mania,  327 
Puerperium,  324 
Pulse  in  mania,  91 

in  neurasthenia,  178 

in  paresis,  287 
Pulse-rate  in  melancholia,  71 
Pupil,  Argyll  Robertson,  in  paresis, 
281 

Hutchinson's,  in  head  injury,  322 

in  dementia  praecox,  123 

in  paresis,  277,  278,  279,  280,  281, 
320 
Pyromania,  193 

impulses  in,  193 

Raptus  melanchoUcus,  74 
Reduction  of  field  of  consciousness 

in  dementia  praecox,  403 
Reflex,  light,  in  paresis,  278,  280 
psychic,  absence  of,  in  dementia 

prsecox,  124 
tendon,  in  confusion,  54 
Repression  of  complexes,  387,  388, 

392 
Respiration  in  melanchoha,  71 

in  paresis,  287 
Rest  cure  in  neurasthenia,  434 
in  treatment,  448 
of  paresis,  444 
Restraining  sheet,  455 
Restraint,  physical,  455,  456 
warm  bath  as  form  of,  455 
pack  as  form  of,  455 
Rheumatic  fever,  211 
dehrium  in,  211 
hallucinations  in,  211 
prognosis,  211 
Rheumatism,  lead,  225 


476 


INDEX 


Sadism,  361 

Saliva  in  paresis,  2S7 

increase  of,  in  mania,  91 
Salt   solution,    hj-podermoclysis    of, 

in  melancholia,  432 
Salvarsan  in  paresis,  305-310 
Schizophrenia,  40S 
Sclerosis,  multiple  cerebrospinal,  312 
paresis    and,    differentiation, 
312 
Scopolamin  in  delirium.  421 

with  morphin  in  deUriiun,  422 
Secretions  in  mania,  91 
Sedatives  in  delirium,  421 
Self-accusatorj-    form    of    paranoia, 

152 
Senile  confusion,  346 
dementia,  203,  345 

senile  melancholia  and,   differ- 
entiation, 351 
sjTnptoms,  203 
mania,  347,  351 
melanchoUa,  351 

senile   dementia   and,    differen- 
tiation, 351 
paranoia,  347 
Senses,    special,     acuteness    of,     in 

mania,  91 
Senma,  imsalvarsanized,   in  paresis, 

308 
Sex  glands  in  dementia  praecox,  131, 

132 
Sexual  abnormaUties,  358 

deficiency,  thjToid  extract  in,  363 
disturbances  in  neurasthenia,  178, 
179 
in  neurasthenic-neuropathic  in- 
sanity, 184 
form  of  h^-pochondria,  375,  376 
hallucinations  in  mystic  paranoia, 
155 
in  paranoia  simplex,  166 
instincts  in  hj-pomania,  95 
perversion,  358 

prognosis  of,  363 
trauma,  390,  400 

in  etiologj'  of  special  fears,  187, 
188 


Sight,   hallucinations  of,  in  melan- 
choUa, 69 
in  mystic  paranoia,  155 
in  paranoia,  148 
simplex,  165 
Sin,  unpardonable,  delusion  of,  24 

in  melancholia,  68 
Sitiophobia  in  melanchoUa,  71 
Skin  in  melanchoUa,  71 

in  paresis,  287 
Skull,  shape  of,  in  paranoia,  142 
SmeU,  hallucinations  of,  in  melan- 
choUa, 70 
in  paranoia,  14S 
Somatic   affections,    mental   disease 
related  to,  206 
delusion,  25 
Somnambulism  in  hysteria,  263 

of  epilepsy,  253 
Soul  weakness,  32,  124,  175,  198 
Spaces,  open,  fear  of,  186 
Specific  febrile  deUrium,  39 
course,  40 

delirium  tremens  and,  differ- 
entiation, 45 
diagnosis,  44 
etiolog}',  40 
pathology,  43 
prognosis,  45 
sjTnptoms,  40 

toxic  deUrium  and,  differen- 
tiation, 45 
Speech  disturbances  in  paresis,  281 
Spinal  tenderness  in  hysteria,  257 
Starvation  in  melanchoUa,  73 
Sterilization   for   prevention   of   in- 
sanity, 414 
Stigmata  of  deviation  and  arrest  in 
etiolog}'  of  heboid-paranoid  group, 
110 
Stomach,  cancer  of,  243 

lavage  of,  in  melanchoUa,  432 
Stupor,  28,  34,  56 

and  confusion,  interrelation,  29 
catatonic  stupor  and,  differentia- 
tion, 59 
course  of,  57,  58 
diagnosis  of,  59 


INDEX 


477 


Stupor,  etiology  of,  30,  57 

hypodermoclysis  in  treatment  of, 

454 
in  childhood,  332 
in  epilepsy,  253 
in  hysteria,  261 
incomplete,  60 
course  of,  61 
prognosis  of,  61 
symptoms  of,  60 
nourishment  in,  425 
prognosis  of,  60 
simple,  28 

stuporous  melancholia  and,  differ- 
entiation, 59 
symptoms  of,  57 
terminal   dementia    as   result   of, 

60 
treatment  of,  425 
with  excitement,  60 
Stuporous  rasanity,  28,  56 

melancholia,    stupor    and,    differ- 
entiation, 59 
Suggestion  in  production  of  symp- 
toms of  hysteria,  259 
Suicide  in  arteriosclerosis,  313 
in  hypomelancholia,  78 
in  insanity  in  childhood,  331 
in  melanchoUa,  72 
prevention  of,  428 
without  delusions,  79 
in  neurasthenic-neuropathic  insan- 
ity, 195,  196 
in  paranoid  dementia,  128 
in  pellagra,  211 
Sulphonal  intoxication,  237 
Surgical  treatment,  444 
Sway  of  body  in  paresis,  277 
Sweating  in  paresis,  287 

in  specific  febrile  delirium,  42 
Symptoms,  19 

psychologic      interpretation      of, 
383 
Syphihs,  207 
cerebral,  310 
in  dementia  praecox,  111 
in  etiology  of  paresis,  267 
in  pathology  of  paresis,  294,  295 


Syphilis  in  production   of  inherited 

neuropathy,  413 
Systematized  delusion,  definition  of, 

23 

Tabes,  318 

ameboid  pupil  in,  320 
paresis  and,  differentiation,  319 
taboparesis    and,    differentiation, 
319,  320 
Taboparesis,  290,  319 

tabes    and,    differentiation,    319, 
320 
Tachycardia   in   neurasthenia,    l'Ji8, 

180 
Taste,  hallucinations  of,  in  melan- 
choHa,  70 
in  paranoia,  147 
simplex,  165 
Temperature  in  mania,  91 
in  melanchoHa,  71 
in  paresis,  288 
Tenderness,  inframammary,  in  hys- 
teria, 257 
inguinal,  in  hysteria,  257 
ovarian,  in  hysteria,  257 
spinal,  in  hysteria,  257 
Tendon  reflexes  in  confusion,  54 
Terminal  dementia,  106 

as  result  of  stupor,  60 
Test,   association,   for  repressed  or 
submerged  complexes,  398 
Lange's  colloidal  gold,  in  paresis, 

304 
mental,     in    feeble-minded     chil- 
dren, 341 
Nonne's  globulin,  in  paresis,  302, 

303 
Wassermann,  in  paresis,  302,  304 
Thoughts  in  mania,  85,  87 
Thrombosis,  314 
Thyroid  deUrium,  243 
prognosis  of,  244 
desiccated,  in  cretinism,  341 
extract  in  neurasthenic  insanities, 
439 
in  sexual  deficiency,  363 
gland,  diseases  of,  243 


478 


INDEX 


Thyroid  gland,   enlargement  of,  in 
dementia  prsccox,  124 
insufficiency      in      neurasthenia- 
neuropathic  insanitj',  184 
Tic  convulsif  in  insanity  of  deficient 
inhibition,  192 
treatment,  440 
in  insanity  of  deficient  inhibition, 
192 
Tics,  190 

treatment  of,  439,  440 
Toxic  deUrium,  specific  febrile  de- 

Urium  and,  differentiation,  45 
Transformation  of  the  personahty, 

141 
Trauma  of  head,  321 
confusion  in,  322 
dehrium  in,  323 
sexual,  390,  400 

in  etiology  of  special  fears,  187, 
188 
Traumarbeit,  396 
Traumverschiebung,  395 
Treatment,  412 
bathing  in,  451 
extramural,  417 
full  feeding  in,  448 
hjTJodermoclysis  in,  454 
intramural,  445 
luminal  sodium  in,  422,  453 
massage  in,  451 
preventive,  412 
rest  in,  448 

restraint,  forms  of,  455 
surgical,  444 
Tremor  in  paresis,  276 
Treponema  pallidum,  discovery  of, 

in  brains  of  paretics,  267,  318 
Trional  in  dehrium,  421 
intoxication,  237 
with  sulphonal  in  dehrium,  421 
Trophic     disturbances    in    paresis, 

288 
Tuberculosis,  208 
confusion  in,  209 
euphoria  in,  209 

ia  production  of  inherited  neurop- 
athy, 413 


Tumor  of  brain,  315 

hallucinations  in,  317 
hysteric  symptoms  in,  318 
symptoms,  315-318 

Tjrphomania,  39 


Ulcer,  perforating,  of  foot,  in  pare- 
sis, 2S8 

Unpardonable  sin,  delusion  of,  24 
in  melancholia,  68 

Unsalvarsanized    serum    in    paresis, 
308 

Unsystematized  delusion,  definition 
of,  24 

Uremic  coma,  241 

Urine  in  diabetic  coma,  239 
in  mania,  91 
in  melanchoUa,  71 
in  paresis,  287 


Verbigeration  in  dementia  praecox, 

122 
Vcrdrangung,  393,  396 
Veronal  intoxication,  237 
Verriicktheit,  139 

acute,  130 
^'erwu•rtheit,  28,  49 
Viscera,  diseases  of,  241 
Visceral  hallucinations  in  paranoia, 
144,  147 
signs  of  melancholia,  70 
sjonptoms  in  hysteria,  257 
of  paresis,  286 
Vision,  hallucinations  of,  in  melan- 
cholia, 69 
in  mystic  paranoia,  155 
in  paranoia,  148 
simplex,  165 


Wahnsixn,  139 

acuter,  130 
Warm  bath,  452 

as  form  of  restraint,  455 
in  afebrile  delirium,  420 
pack  as  form  of  restraint,  455 


INDEX 


479 


Wassermann  reaction  in  paresis,  267, 
302,  304 
in  dementia  praecox,  111 
Weight  in  paresis,  287 

loss  of,  in  melancholia,  71 
Weir  Mitchell  rest  cure,  434 


Wet  pack  in  afebrile  deUrium,  420 
Will,  deficient,  insanity  of,  196 
Witzelsucht,  316 
Worry  in  melancholia,  66 

ZWANGSNEUROSE,  190 


SAUNDERS'  BOOKS 


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Davis*   Accessory  Sinuses 

Development  and  Anatomy  of  the  Nasal  Accessory  Sinuses  in 
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Fellow  of  the  Jefferson  Medical  Colleg-e,  Philadelphia.  Octavo  of  172 
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ORIGINAL   DISSECTIONS 

This  book  is  based  on  the  study  of  two  hundred  and  ninety  lateral  nasal  walls, 
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work  and  personal  dissections  of  Dr.  Davis  at  the  Daniel  Baugh  Institute  of 
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A  Treatise  on  Diseases  of  the  Skin.  By  Henry  W.  Stelwagon, 
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Schamberg's  Diseases  (jf  the  Skin 
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Diseases  of  the  Skin  and  the  Eruptive  Fevers.  By  J.ay  F.  Schamberg, 
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GENI TO- URINARY  DISEASES 


Norris* 
Gonorrhea  in  Women 

Gonorrhea  in  Women.  By  Charles  C.  Norris,  M.  D.,  Instructor 
in  Gynecology,  University  of  Pennsylvania,  with  an  Introduction  by 
John  G.  Clark,  M.  D.,  Professor  of  Gynecology,  University  of  Penn- 
sylvania.    Large  octavo  of  520  pages,  illustrated.  Cloth,  ^6.50  net. 

A  CLASSIC 

Dr.  Norris  here  presents  a  work  that  is  destined  to  take  high  place  among 
publications  on  this  subject.  He  has  done  his  work  thoroughly.  He  has  searched 
the  important  literature  very  carefully,  over  2300  references  being  utilized. 
This,  coupled  with  Dr.  Norris'  long  experience,  gives  his  work  the  stamp  of 
authority.  The  chapter  on  serum  and  vaccine  therapy  and  organotherapy  is 
particularly  valuable  because  it  expresses  the  newest  advances.  Every  phase  of 
the  subject  is  considered. 

Pennsylvania  Medical  Journal 

"  Dr.  Norris  has  succeeded  in  presenting  most  comprehensively  the  present  knowledge  ol 
gonorrhea  in  women  in  its  many  phases.  The  present  status  of  serum  and  vaccine  therapy  is 
given  in  detail." 


Braasch*s  Pyelography 

Pyelography.  By  William  F.  Braasch,  M.  D.,  The  Mayo  Clinic, 
Rochester,  Minn.  Octavo  of  323  pages,  with  296  pyelograms.  Cloth, 
I5.00  net. 

A   NEW   WORK 

Dr.  Braasch's  new  work  is  the  first  comprehensive  collection  of  the  various  types  of 
pelvic  outlines,  both  normal  and  pathologic.  You  get  here  296  skiagrams  of  the  renal  pel- 
vis and  ureter,  selected  from  several  thousand  plates  made  at  the  Mayo  Clinic.  These  pye- 
lograms, together  with  the  clear  descriptions,  constitute  an  admirable  aid  to  the  differential 
diagnosis  of  the  various  conditions  affecting  the  renal  pelvis.  The  characteristic  pelvic  out- 
line in  each  disease  is  first  shown  you  by  the  excellent  pyelograms;  then  Dr.  Braasch  inter- 
prets these  pyelograms  for  you  in  diagnostic  terms.  You  get  the  history  of  pyelography,  the 
exact  technic  (selection  of  the  medium,  preparation  of  solution,  method  of  injection,  sources 
of  error,  results),  the  normal  pelves,  the  various  pathologic  outlines,  and  the  outlines  in  con- 
genital anomalies.     It  is  a  most  complete  work. 


SAUNDERS'     BOOKS    ON 


Barn  hill   and  Wales* 
Modern   Otology 

A  Text-Book  of  Modern  Otology.  By  John  F.  Barnhill,  M.  D., 
Professor  of  Otology,  Laryngolog)',  and  Rhinology,  and  Earnest 
DE  \V.  Wales,  M.  D.,  Associate  Professor  of  Otology,  Laryngology, 
and  Rhinology,  Indiana  University  School  of  Medicine,  Indianapolis. 
Octavo  of  598  pages,  with  314  original  illustrations.  Cloth,  $5.50  net; 
Half  Morocco,  ^7.00  net. 

THE  NEW  f2d)  EDITION 

The  authors,  in  writing  this  work,  kept  ever  in  mind  the  needs  of  the 
physician  engaged  in  general  practice.  It  represents  the  results  of  personal 
experience  as  practitioners  and  teachers,  influenced  by  the  instruction  given  by 
such  authorities  as  Sheppard,  Dundas  Grani,  Percy  Jakins,  Jansen,  and  Alt. 
Much  space  is  devoted  to  prophylaxis,  diagnosis,  and  treatment,  both  medical 
and  surgical.  There  is  a  special  chapter  on  the  bacteriology  of  ear  affections — 
a  feature  not  to  be  found  in  any  other  work  on  otology.  Great  pains  have  been 
taken  with  the  illustrations,  in  order  to  have  them  as  practical  and  as  helpful  as 
possible,  and  at  the  same  time  highly  artistic.  A  large  number  represent  the 
best  work  of  Mr.  H.  F.  Aitken. 


Coolidge  on  Nose  and  Throat 

Manual  of  Diseases  of  the  Nose  and  Throat.  By  Algernon  Cool- 
IDGE,  M.  D.,  Professor  of  Laryngology,  Harvard  Medical  School. 
Octavo  of  360  pages,  illustrated.     Cloth,  $1.50  net. 

This  new  book  furnishes  the  student  and  practitioner  a  guide  and  ready  reference  to  the 
important  details  of  examination,  diagnosis,  and  treatment.  Established  facts  are  empha- 
sized and  unproved  statements  avoided.  Anatomy  and  physiology  of  the  different  regions 
are  included. 

Frank  AUport.  M.  D. 

Professor  of  Otology,  Northwestern  University^  Chicago. 

"  I  regard  it  as  one  of  the  best  books  in  the  English  language  on  this  subject.  The 
pictures  are  especially  good,  particularly  as  they  are  practically  all  original  and  not  the  old 
reproduced  pictures  so  frequently  seen." 


DISEASES   OF   THE  EYE, 


DeSchweinitz's 
Diseases  of  the  Eye 

Just  Out— New  (8th)  Edition 

Diseases  of  the  Eye:  A  Handbook  of  Ophthalmic  Practice. 
By  G.  E.  deSchweixitz,  M.D.,  Professor  of  Ophthalmology  in  the  Uni- 
versity of  Pennsylvania,  Philadelphia,  etc.  Handsome  octavo  of  754 
pages,  386  text-illustrations,  and  7  chromo-lithographic  plates.  Cloth, 
$6.00  net;  Sheep  or  Half  Morocco,  $7.50  net. 

THE  STANDARD  AUTHORITY 

The  new  matter  added  includes:  Walker's  testing  of  visual  field,  squirrel 
plague  conjunctivitis,  swimming  bath  conjunctivitis,  anaphylactic  keratitis,  family 
cerebral  degeneration  with  macular  changes,  ocular  symptoms  of  pituitary 
disease,  sclerectomy  with  a  punch,  preliminary  capsulotomy,  iridotasis,  thread 
drainage  of  anterior  chamber,  extraction  of  cataract  in  capsule  after  subluxation 
of  lens  with  capsule  forceps,  capsulomuscular  advancement  with  partial  resection, 
tenotomy  of  inferior  oblique,  window  resection  of  nasal  duct. 


Bass   and  Johns*   Alveolodental   Pyorrhea 

Alveolodental  Pyorrhea.  By  Charles  C.  Bass,  M.  D.,  Professor 
of  Experimental  Medicine,  and  Foster  M.  Johns,  M.  D.,  Instructor  in 
the  Laboratories  of  Clinical  Medicine,  Tulane  Medical  College.  Octavo 
of  168  pages,  illustrated.  Cloth,  $2.50  net, 

Drs.  Bass  and  Johns  present  their  subject  from  the  viewpoint  of  infection  by 
the  Endamoeba  buccalis.  You  get  a  full  account  of  the  Endamoeba  buccalis,  the 
historj'  of  disease,  the  morbid  processes,  contagiousness,  symptomatology,  how 
to  make  your  diagnosis  from  the  history  and  microscopic  examination,  prophy- 
laxis, and  the  exact  technic  for  using  emetin  hydrochlorid.  You  get  the  action 
of  emetin  upon  the  Endamoeba,  you  get  the  exact  dosage,  you  get  the  interval 
between  doses,  the  local  effect,  the  urticaria  produced,  the  tecknic  of  injection. 

University  of  Pennsylvania  Medical  Bulletin 

"Upon  reading  through  the  contents  of  this  book  we  are  impressed  by  tne  remarkable 
fulness  with  which  it  reflects  the  notable  contributions  recently  made  to  ophthalmic  literature. 
No  important  subject  within  its  province  has  been  neglected." 


SAUNDERS'  BOOKS   ON 


GET  ^  ^  T"^  NEW 

THE    BEST  A  ni  C  r  1  C  2i  11  STANDARD 

Illustrated   Dictionary 

New  (8th)  Edition— 1500  New  Terms 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surger>',  Dentistry, 
Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches;  with  over  100  new  and  elaborate  tables  and  many  illustra- 
tions. By  W.  A.  Newman  Borland,  M.D.,  Editor  of  "  The  American 
Pocket  Medical  Dictionary."  Large  octavo,  with  1 137  pages,  bound  in 
full  flexible  leather.     Price,  $4.50  net ;  with  thumb  index,  ;^5.00  net. 

KEY  TO  CAPITALIZATION  AND  PRONUNCIATION— ALL  THE  NEW  WORDS 

This  dictionary  is  the  "new  standard."  It  defines  hundreds  of  the  newcbi 
terms  not  defined  in  any  other  dictionary — bar  none.  These  terms  are  hve, 
active  words,  taken  right  from  modern  medical  Hterature. 

Howard  A.  Kelly.  M.  D., 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University,  Baltimore 

"  Dr.  Dorlands  Dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 
siie.     No  errors  have  been  found  in  my  use  of  it." 


Theobald's  Prevalent  Eye  Diseases 


Prevalent  Diseases  of  the  Eye.  By  Samuel  Theobald,  M.  D., 
Clinical  Professor  of  Ophthalmology  and  Otology,  Johns  Hopkins 
University.  Octavo  of  55opages,  with  219  text-cuts  and  several  colored 
plates.     Cloth,  S4oO  net;  Half  Morocco,  ^6.00  net. 

THE    PRACTITIONER'S    OPHTHALMOLOGY 

With  few  exceptions  all  the  works  on  diseases  of  the  eye,  although  written 
ostensibly  for  the  general  practitioner,  are  in  reality  adapted  only  to  the  speciahst  ; 
but  Dr.  Theobald  in  his  book  has  described  verj'  clearly  and  in  detail  those  condi- 
tions, the  diagnosis  and  treatment  of  which  come  withm  the  province  of  the  general 
practitioner.  The  therapeutic  suggestions  are  concise,  unequivocal,  and  specific. 
It  is  the  one  work  on  the  Eye  written  particularly  for  the  general  practitioner. 

Charles  A.  Oliver,  M.D., 

Clinical  Professor  of  Ophthalmology,  Woman's  Medical  College  of  Pennsylvania, 

"  I  feel  I  can  conscientiously  recommend  it,  not  only  to  the  general  physician  and  medical 

student,   for  whom  it  is  primarily  written,  but  also  to  the  experienced  ophthalmologist.     Most 

surely  Dr.  Theobald  has  accomplished  his  purpose." 


DISEASES    OF   THE  EYE. 


Haab  and  DeSchweinitz*s 
External  Diseases  qf  the  Eye 


Atlas  and  Epitome  of  External  Diseases  of  the  Eye.     By  Dr.  O. 

Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E.  deSchweinitz, 
M.  D.,  Professor  of  Ophthalmology,  University  of  Pennsylvania.  With 
loi  colored  illustrations  on  46  lithographic  plates  and  244  pages  of 

text.     Cloth,  $3.00  net.     In  Saunders'  Hand-Atlas  Series. 

THIRD  EDITION 

Conditions  attending  diseases  of  the  external  eye,  which  are  often  socompHcated, 
have  probably  never  been  more  clearly  and  comprehensively  expounded  than  in 
the  forelying  work,  in  which  the  pictorial  most  happily  supplements  the  verbal 
description.     The  price  of  the  book  is  remarkably  low. 

The  Medical  Record,  New  York 

"  The  work  is  excellently  suited  to  the  student  of  ophthalmology  and  to  the  practising 
physician.     It  cannot  fail  to  attain  a  well-deserved  popularity." 


Haab  and  DeSchweinitzV 
Ophthalmoscopy 


Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthalmoscopic 
Diagnosis.  By  Dr.  O.  Haab,  of  Zurich.  Edited,  with  additions,  by 
G.  E.  deSchweinitz,  M.  D.,  Professor  of  Ophthalmology,  University 
of  Pennsylvania.  With  152  colored  lithographic  illustrations  and  92 
pages  of  text.     Cloth,  ^3.00  net.     In  Saunders'  Hand- Atlas  Series. 

SECOND  EDITION 

The  great  value  of  Prof.  Haab's  Atlas  of  Ophthalmoscopy  and  Ophthalmo- 
scopic Diagnosis  has  been  fully  established  and  entirely  justified  an  Enghsh 
translation.  Not  only  is  the  student  made  acquainted  with  carefully  prepared 
ophthalmoscopic  drawings  done  into  well-executed  lithographs  of  the  most  im- 
portant fundus  changes,  but,  in  many  instances,  plates  of  the  microscopic  lesions 
are  added.     The  whole  furnishes  a  manual  of  the  greatest  possible  service. 

The  Lancet,  London 

"We  recommend  it  as  a  work  that  should  be  in  the  ophthalmic  wards  or  in  the  library  of 
every  hospital  into  which  ophthalmic  cases  are  received." 


SAr.yPE/^S'    BOCA'S  ON 


Head's  Mouth  Infections 

Mouth  Infections.     By  Joseph  Head,  M.  D.  ,  D.  D.  S.     Octavo  of 
350  pages,  with  310  illustrations.  Ready  Soon. 

THE  RESULT  OF  30  YEARS'  ACTIVE  PRACTICE 

That  gum  and  tooth  infections  may  originate  valvular  heart  disease,  pernicious 
anemia,  arthritis  deformans,  rheumatism,  and  nervous  derangements  there  is  re- 
peated clinical  proof.  Dr.  Head,  a  specialist  in  this  field,  cites  case  after  case  of 
organic  diseases — ^just  such  cases  as  come  into  your  office  for  treatment  daily — 
which  he  has  traced  to  lesions  in  the  gums  due  to  infection,  and  cured  of  both  local 
and  systemic  affections.  He  gives  you  the  principles,  the  technic  in  full,  and  his 
original  formulae  and  methods.  You  get  sections  on  diagnosis,  treatment,  mouth 
hygiene,  local  anesthesia  by  novocain,  electrolysis,  tooth  discoloration,  care  of 
children's  teeth,  orthodontia,  cement,  .r-ray  study,  use  of  emetin,  and  of  vaccines. 
It  is  a  book  of  wide  and  varied  application,  of  vital  importance,  and  of  true  scien- 
tific value.  It  appeals  first  to  the  dentist  and  dental  surgeon,  but  it  appeals  strongly 
to  the  general  practitioner,  surgeon,  and  specialist  because  of  the  recognized  im- 
portance of  mouth  infections  as  factors  in  the  etiology  of  organic  disease. 

Kyle's 
Diseases  of  Nose  am)  Throat 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D., 
Professor  of  Laryngology  in  the  Jefferson  Medical  College,  Phila' 
delphia.  Octavo,  825  pages;  with  258  illustrations,  28  in  colors. 
Cloth,  $4.50  net;  Half  Morocco^  ^6.00  net. 

THE  NEW  rsth)  EDITION 

The  new  {sth)  edition  of  Dr.  Kyle's  work  shows  an  increase  of  100 pages  axid 
some  40  new  Uliistratiotis,  The  following  7ieu<  articles  have  been  added  :  vaccine 
therapy  ;  lactic  bacteriotherapy;  salvarsan  in  the  treatment  of  syphilis  of  the  upper 
respirator)-  tract ;  sphenopalatine  ganglia  neuralgia  ;  negative  air-pressure  in  ac- 
cessory sinus  disease  ;  chronic  hyperplastic  ethmoiditis  ;  and  congenital  insuffi- 
ciency of  the  palate.  The  tables  of  differential  diagnosis  and  the  prescriptions  are 
striking  points  of  Dr.  Kyle's  book. 

Pennsylvania  Medical  JoumzJ 

"  Dr.  Kyle's  crisp,  terse  diction  has  enabled  the  inclusion  of  all  needful  nose  and  throat 
knowledge  in  this  book." 


URINE  AND   IMPOTENCE. 


O^den  on  the  Urine 


Clinical  Examination  of  Urine  and  Urinary  Diagnosis.  A  Clinical 
Guide  for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Sur- 
gery. By  J.  Bergen  Ogden,  M.  D.,  Medical  Chemist  to  the  Metro- 
politan Life  Insurance  Company,  New  York.  Octavo,  418  pages,  54 
text  illustrations,  and  a  number  of  colored  plates.     Cloth,  ^3.00  net. 

THIRD  EDITION 

In  this  edition  the  work  has  been  brought  absolutely  down  to  the  present  day 
Urinary  examinations  for  purposes  of  hfe  insurance  have  been  incorporated,  because 
a  large  number  of  practitioners  are  often  called  upon  to  make  such  analyses. 
Special  attention  has  been  paid  to  diagnosis  by  the  character  of  the  urine,  the 
diagnosis  of  diseases  of  the  kidneys  and  urinary  passages  ;  an  enumeration  of  the 
prominent  clinical  symptoms  of  each  disease  ;  and  the  peculiarities  of  the  urine 
in  certain  general  diseases. 

The  Lancet,  London 

"  We  consider  this  manual  to  have  been  well  compiled  ;  and  the  author's  own  experience, 
sp  clearly  stated,  renders  the  volume  a  useful  one  both  for  study  and  reference." 


Pilcher*s 
Practical  Cystoscopy 

Practical  Cystoscopy.  By  Paul  M.  Pilcher,  M.  D.,  Consulting 
Surgeon  to  the  Eastern  Long  Island  Hospital.  Octavo  of  504  pages, 
with  299  illustrations,  29  in  colors.      Cloth,  $6.00  net, 

NEW  (2d)  EDITION 

Cystoscopy  is  to-day  the  most  practical  manner  of  diagnosing  and  treating 
diseases  of  the  bladder,  ureters,  kidneys,  and  prostate.  To  be  properly  equipped, 
therefore,  you  must  have  at  your  instant  command  the  information  this  book  gives 
you.  It  explains  away  all  difficulty,  telling  you  luhy  you  do  not  see  something 
when  something  is  there  to  see,  and  telling  you  how  to  see  it.  All  theory  has 
been  uncompromisingly  eliminated,  devoting  every  line  to  practical,  needed- 
every-day  facts,  telling  you  how  and  when  to  use  the  cystoscope  and  catheter — 
telling  you  in  a  way  to  make  you  know.  The  work  is  complete  in  every  detail. 
Bransford  Lewis,  M.  D.,  St.  Louis  University. 

"  I  am  very  much  pleased  with  Dr.  Pilcher's  '  Practical  Cystoscopy.'  I  think  it  is  the  best 
in  the  English  language  now." — April  2-j,  igii. 


lo  SAUNDERS-   BOOKS    ON 


Goepp*s 
Dental  State  Boards 

Dental  State  Board  Questions  and  Answers — By  R.  Max  Goepp, 
M.  D.,  author  "  Medical  State  Board  Questions  and  Answers."  Octavo 
of  428  pages.     Cloth,  $3.00  net. 

SECOND  EDITION 

This  new  work  is  along  the  same  practical  lines  as  Dr.  Goepp' s  successful  work 
on  Medical  State  Boards.  The  questions  included  have  been  gathered  from  reliable 
sources,  and  embrace  all  those  likely  to  be  asked  in  any  State  Board  examination 
in  any  State.  They  have  been  arranged  and  classified  in  a  way  that  makes  for  a 
rapid  resume  of  every  branch  of  dental  practice,  and  the  answers  are  couched  in 
language  unusually  explicit — concise,  definite,  accurate. 

The  practicing  dentist,  also,  will  find  here  a  work  of  great  value — a  work 
covering  the  entire  range  of  dentistry  and  extremely  well  adapted  for  quick 
reference. 


Haab  and  deSchweinitz*s 
Operative  Ophthalmology 

Atlas  and   Epitome  of   Operative    Ophthalmology.       By  Dr.  O. 

Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E.  deSchweinitz, 
M.  D.,  Professor  of  Ophthalmology  in  the  University  of  Pennsylvania. 
With  30  colored  lithographic  plates,  1 54  text-cuts,  and  375  pages  of 
text.     In  Saunders'  Hand-Atlas  Series.     Cloth,  $3.50  net. 


Dr.  Haab's  Atlas  of  Operative  Ophthalmology  will  be  found  as  beautiful  and 
as  practical  as  his  two  former  atlases.  The  work  represents  the  author' s  thirty 
years'  experience  in  eye  work.  The  various  operative  interventions  are  described 
with  all  the  precision  and  clearness  that  such  an  experience  brings.  Recognizing 
the  fact  that  mere  verbal  descriptions  are  frequently  insufficient  to  give  a  clear 
idea  of  operative  procedures.  Dr.  Haab  has  taken  particular  care  to  illustrate 
plainly  the  different  parts  of  the  operations. 

Johns  Hopkins  Hospital  Bulletin 

'■  The  descriptions  of  the  various  operations  are  so  clear  and  full  that  the  volume  can  well 
hold  place  with  more  pretentious  text-books." 


GENITO-URINARY   AND    NOSE,     THROAT,     ETC.  il 

Greene  anb  Brooks' 
Genito-Urinary  Diseases 

Diseases  of    the    Qenito=Urinary  Organs  and  the  Kidney.      By 

Robert  H.  Greexe,  M.  D.,  Professor  of  Genito-Urinary  Surgerj-  at 
Fordham  Universit}^ ;  and  Harlow  Brooks,  M.  D.,  Assistant  Pro- 
fessor of  Clinical  Medicine,  University  and  Bellevue  Hospital  ^Medical 
School.  Octavo  of  639  pages,  illustrated.  Cloth,  $5.00  net;  Half 
Morocco,  $6.50  net. 

THIRD  EDITION 

This  new  work  presents  both  the  medical  and  surgical  sides.  Designed  as  a 
work  of  quick  reference,  it  has  been  written  in  a  clear,  condensed  style,  so  that 
the  information  can  be  readily  grasped  and  retained.  Kidney  diseases  are  very 
elaborately  detailed. 

New  York  Medical  Journal 

"  As  a  whole  the  book  is  one  of  the  most  satisfactory  and  useful  works  on  genito-urinarv 
diseases  now  extant,  and  will  undoubtedly  be  popular  among  practitioners  and  students." 

Gleason  on  Nose,  Throat, 
and  Ear 

A   Manual   of   Diseases  of   the    Nose,  Throat,  and    Ear.     By  E. 

Baldwin  Gleasox,  ^I.  D.,  LL.  D.,  Professor  of  Otology,  Medico- 
Chirurgical  College,  Graduate  School  of  Medicine,  Universit}-  of  Penn- 
sylvania.     i2mo  of  590  pages,  profusely  illustrated.     Cloth,  $2.75  net. 

THIRD   EDITION 

Methods  of  treatment  have  been  simplified  as  much  as  possible,  so  that  in 
most  instances  only  those  methods,  drugs,  and  operations  have  been  advised 
which  have  proved  beneficial.  A  valuable  feature  consists  of  the  collection  of 
formulas. 

American  Journal  of  the  Medical  Sciences 

"  For  the  practitioner  who  \sashes  a  reliable  guide  in  laryngolog}-  and  otology  there  are  few 
books  which  can  be  more  heartily  commended." 


SAUNDERS'   BOOKS  ON 


Holland's  Medical 
Chemistry  and  Toxicolog>y 

A  Text-Book  of  Medical  Chemistry  and  Toxicology.  By  James 
\V.  Holland,  M.  D.,  ICmeritus  Professor  of  Medical  Chemistry  and 
Toxicology,  and  Dean,  Jefferson  Medical  College,  Philadelphia.  Octavo 
of  678  pages,  fully  illustrated.     Cloth,  $3.00  net. 

FOURTH  EDITION 

Dr.  Holland's  work  is  an  entirely  new  one,  and  is  based  on  his  forty  years* 
practical  experience  in  teaching  chemistry  and  medicine.  It  has  been  subjected  to 
a  thorough  revision,  and  enlarged  to  the  extent  of  some  sixty  pages.  The  additions 
to  be  specially  noted  are  those  relating  to  the  electronic  theory,  chemical  equilib- 
rium, Kjeldahl's  method  for  determining  nitrogen,  chemistry  of  foods  and  their 
changes  in  the  body,  synthesis  of  proteins,  and  the  latest  improvements  in  urinary 
tests.      .More  space  is  given  to  toxicology  than  in  any  other  text-book  on  chemistry. 

American  Medicine 

"  Its  statements  are  clear  and  terse  ;  its  illustrations  well  chosen  ;  its  development  logical, 
systematic,  and  comparatively  easy  to  follow.  .  .  .  We  heartily  commend  the  work." 

Ivy*s  Applied  Anatomy  and 

Oral  Surgery  for  Dental  Students 


Applied   Anatomy  and   Oral   Surgery  for  Dental  Students.     By 

Robert  H.  Ivy,  M.D.,  D.D.S.,  Assistant  Oral  Surgeon  to  the  Philadel- 
phia General  Hospital.      i2mo  of  280  pages,  illustrated.     Cloth,  ;^i. 50 

net. 

FOR  DENTAL  STUDENTS 

This  work  is  just  what  dental  students  have  long  wanted — a  concise,  practical 
work  on  applied  anatomy  and  oral  surgery,  written  with  their  needs  solely  in 
mind.  No  one  could  be  better  fitted  for  this  task  than  Dr.  Ivy,  who  is  a  graduate 
in  both  dentistry  and  medicine.  Having  gone  through  the  dental  school,  he 
knows  precisely  the  dental  student's  needs  and  just  how  to  meet  them.  His 
medical  training  assures  you  that  his  anatomy  is  accurate  and  his  technic  modern. 
The  text  is  well  illustrated  with  pictures  that  you  will  find  extremely  helpful. 

H.  P.  Kuhn,  M.D.,  IVcstem  Dental  College,  Kansas  City. 

"  I  am  delighted  with  this  compact  little  treatise.     It  seems  to  me  just  to  fill  the  bill." 


CHEMISTRY,   SKIN,   AND    VENEREAL    DISEASES.  15 

American  Pocket  Dictionary  New  9th)  Edition 

The  American  Pocket  Medical  Dictionary.    Edited  by  W.  A. 

Newman  Borland,  M.  D.,  Editor  "American  Illustrated  Medical 

Dictionary."     Containing  the  pronunciation  and  definition   of  the 

principal  words  used  in  medicine  and  kindred  sciences.    693   pages. 

Flexible  leather,  with  gold  edges,  $1.25    net;  with  thumb  index, 

$1.50  net. 

James  W.  Holland,  M.  D., 

Professor  of  Medical  Chemistry  and  Toxicology,  and  Dean,  Jefferson  Medical  College, 
Ph  ila  delphia, 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.  1 
can  recommend  it  to  our  students  without  reserve." 

Stelwagon*s  Essentials  of  Skin  7th  Edition 

Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stel- 
WAGON,  M.  D.,  Ph.D.,  Professor  of  Dermatolog}^  in  the  Jeffer- 
son Medical  College,  Philadelphia.  Post-octavo  of  291  pages, 
with  72  text-illustrations  and  8  plates.  Cloth,  31.25  net.  In 
Saunders'  Question-  Compend  Series, 
The  Medical  News 

"  In  line  with  our  present  knowledge  of  diseases  of  the  skin.  .  .  .  Continues  to  main- 
tain the  high  standard  of  excellence  for  which  these  question  compends  have  been  noted.' 

Wolffs  Medical  Chemistry  seventh  Edition 

Essentials  of  Medical  Chemistry,  Organic  and  Inorganic, 
Containing  also  Questions  on  Medical  Physics,  Chemical  Physiol- 
ogy, Analytical  Processes,  Urinalysis,  and  Toxicolog}'.  By  Law- 
rence Wolff,  M.  D.,  Late  Demonstrator  of  Chemistr}',  Jefferson 
Medical  College.  Revised  by  A.  Ferree  Witmer,  Ph.  G.,  M.  D., 
Formerly  Assistant  Demonstrator  of  Physiology,  University  of 
Pennsylvania.  Post-octavo  of  222  pages.  Cloth,  $1.25  net.  In 
Sannders''  Question- Compend  Series. 

Vecki's  Sexual  Impotence  New  (5th)  Edition 

Sexual  Impotence.  By  Victor  G.  Vecki,  M.  D.,  Consulting 
Genito-Urinary  Surgeon  to  Mt.  Zion  Hospital,  San  Francisco. 
i2mo  of  405  pages.     Cloth,  ^2.25  net. 

Johns  Hopkins  Hospital  Bulletin 

"A  scientific  treatise  upon  an  important  and  much  neglected  subject.  .  .  .  The 
treatment  of  impotence  in  general  and  of  sexual  neurasthenia  is  discriminating  and 
judicious." 

Wilcox  on  Genito-Urinary  and  Venereal  Diseases 

Second  Edition 

Essentials  of  Genito-Urinary  and  Venereal  Diseases.  By 
Starling  S.  Wilcox,  M.  D.,  Lecturer  on  Genito-Urinar}-  Diseases 
and  Syphilology,  Starling-Ohio  Medical  College,  Columbus.  i2mo 
of  321  pages,  illustrated.     Cloth,  I1.25  net.     Saunders'  Compends. 


14  SAUNDERS'    BOOKS   ON 


Second 
Edition 


Wells*  Chemical  Pathology 

Chemical  Pathology.  Being  a  discussion  o^  General  Path- 
ology from  the  Standpoint  of  the  Chemical  Proc^^sses  Involved. 
By  H.  Gideon  Wells,  Ph.  D.,  M,  D.,  Assistanv  Professor  of 
Pathology  in  the  University  of  Chicago.  Octavo  of  6i6  pages. 
Cloth,  ^3.25  net. 

Wm.   H.  Welch,  M.  D.,  Professor  of  Pathology,  Johns  H->pkins  University. 

"  The  work  fills  a  real  need  in  the  English  literature  of  a  very  iniportanr  subject,  and 
1  shall  be  glad  to  recommend  it  to  my  students." 


Fourth 
Revised  Edition 


Jackson's  Essentials  of  Eye 

Essentials  of  Refraction   and    of   Diseases   of  the    Eye.     By 

Edward  Jackson,  A.  M.,  M.  D.,  Emeritus  Professor  of  Diseases  of 
the  Eye,  Philadelphia  Polyclinic.  Post-octavo  of  261  pages,  82  illus- 
trations.    Cloth,   $1.25   net.      In  Saunders'  Question-Compend  Scries. 

Johns  Hopkins  Hospital  Bulletin 

"The  entire  ground  is  cove/ed,  and  the  points  that  most  need  careful  elucidation  are 
made  clear  and  easy." 

Gleason's  Nose  and  Throat     ''°"'"'  Klf^j 

Essentials  of  Diseases    of  the   Nose  and   Throat.     By  E.  B. 

Gleason,  S.  B.,  M.  D.,  Clinical  Professor  of  Otology,  Medico- 
Chirurgical  College  ;  Graduate  School  of  Medicine,  University  of 
Pennsylvania.  Post-octavo,  241  pages,  112  illustrations.  Cloth. 
$1.25   net.      In  Saunders'  Question  Compends. 

The  Lancet,  London 

"  The  careful  description  which  is  given  of  the  various  procedures  would  be  sufficient 
to  enable  most  people  of  average  intelligence  and  of  slight  anatomical  knowledge  to  make 
a  very  good  attempt  at  laryngoscopy." 

Grtinwald  and  Grayson  on  the  Larynx 

Atlas  and  Epitome  of  Diseases    of  the  Larynx.     By  Dr.  L. 

Grunwald,  of  Munich.  Edited,  with  additions,  by  Charles  P. 
Grayson,  M.D.,  University  of  Pennsylvania.  With  107  colored 
figures  on  44  plates,  25  text-cuts,  and  103  pages  of  text.  Cloth, 
;^2.50  net.     In  Saunders'  Hand- Atlas  Scries. 

Mracek  and  Stelwag'on's  Atlas  of  Skin         |^^S°2 

Atlas  and  Epitome  of  Diseases  of  the  5kin.  By  Prof.  Dr. 
Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by  Henry 
W.  Stelwagon,  M.D.,  Jefferson  Medical  College.  With  "jj  col- 
ored plates,  50  half-tone  illustrations,  and  280  pages  of  text.  In 
Saunders'  Hand-Atlas  Series.     Cloth,  $400  net. 


EYE,    EAR,    NOSE,    AND    THROAT. 


deSchweinitz   and    Holloway   on   Pulsatin|(    Exoph- 
thalmos 

Pulsating  Exophthalmos.  An  analysis  of  sixty-nine  cases  not  pre- 
viously analyzed.  By  George  E.  deSchweinitz,  M.  D.,  and  Thomas 
B.  Holloway,  M.  D.     Octavo  of  125  pages.     Cloth,  ^2.00  net. 

This  monograph  consists  of  an  analysis  of  sixty-nine  cases  of  this  affection 
not  previously  analyzed.  The  therapeutic  measures,  surgical  and  otherwise, 
which  have  been  employed  are  compared,  and  an  endeavor  has  been  made 
to  determine  from  these  analyses  which  procedures  seem  likely  to  prove  of 
the  greatest  value.  It  is  the  most  valuable  contribution  to  ophthalmic  liter- 
ature within  recent  years. 

Sritish  Medical  Journal 

"  The  book  deals  very  thoroughly  ■with  the  whole  subject  and  in  it  the  most  complete  account  ot 
the  disease  will  be  found." 

Jackson     on     the     Eye  Preparing  New  Od)  Edition 

A  Manual  of  the  Diagnosis  and  Treatment  of  Diseases  of  the 
Eye.  By  Edward  Jackson,  A.  M.,  M.  D.,  Professor  of  Ophthalmology, 
University  of  Colorado.  i2mo  volume  of  615  pages,  with  184  beautiful 
illustrations. 

The  Medical  Record,  New  York 

"  It  is  truly  an  admirable  work.  .  .  .  Written  in  a  clear,  concise  manner,  it  bears  evidence  of  the 
author's  comprehensive  grasp  of  the  subject.  The  term  'multum  in  parvo'  is  an  appropriate  one  to 
apply  to  this  work." 

Grant  on   Face,   Mouth,   and  Jaws 

A  Text-Book  of  the  Surgical  Principles  and  Surgical  Diseases 
OF  the  Face,  Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace 
Grant,  A.  M.,  M.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Hospital  College  of  Medicine,  Louisville.  Octavo  of  231  pages,  with 
68  illustrations.     Cloth,  ^2.50  net. 

Preiswerk  and  Warren's  Dentistry 

Atlas  and  Epitome  of  Dentistry.  By  Prof.  G.  Preiswerk,  of 
Basil.  Edited,  with  additions,  by  George  W.  Warren,  D.D.S.,  Pro- 
fessor of  Operative  Dentistry,  Pennsylvania  College  of  Dental  Surgery, 
Philadelphia.  With  44  lithographic  plates,  152  text-cuts,  and  343  pages 
of  text.      Cloth,  $3.50  net.     I71  Saunders'  Atlas  Series. 

Asher*s  Chemistry  and  Toxicology 

Chemistry  and  Toxicology  for  Nurses.  By  Philip  Asher,  Ph.G., 
M.  D.,  Dean  and  Professor  of  Chemistry,  New  Orleans  College  of  Phar- 
macy.     i2mo  of  190  pages.     Cloth,  $1.25  net. 


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